2017

Resident Manual

WEST VIRGINIA UNIVERSITY

PLASTIC SURGERY RESIDENCY

MISSION STATEMENT ................................................................................................. 1

INTRODUCTION ........................................................................................................... 2

EDUCATIONAL GOAL .................................................................................................. 2

ACGME COMPETENCIES ............................................................................................ 2

SUPERVISION POLICY ................................................................................................. 4

EDUCATIONAL CONFERENCES ................................................................................. 7

SKILLS LAB SESSIONS ................................................................................................. 8

PLASTIC SURGERY CASE LOG POLICY ...................................................................... 9

CORE REQUIREMENTS FOR INTEGRATED PROGRAM .......................................... 10

OPERATIVE MINIMUMS FOR PLASTIC SURGERY ................................................... 10

RESEARCH POLICY ................................................................................................... 14

ABSITE EXAM/ PLASTIC SURGERY IN-SERVICE EXAM .......................................... 14

USMLE/LICENSE POLICY .......................................................................................... 14

EXPECTATIONS OF A RESIDENT’S BEHAVIOR: ...................................................... 15

CALL RESPONSIBILITIES: ........................................................................................ 16

CODE OF PROFESSIONALISM .................................................................................. 16

TRAUMA COVERAGE POLICY ................................................................................... 18

PHOTOGRAPHY POLICY............................................................................................ 19

EMAIL GUIDELINES ..................................................................................................19

DUTY HOUR POLICY ................................................................................................. 19

AT HOME CALL .......................................................................................................... 27

TRANSITIONS OF CARE ............................................................................................ 27

EVALUATION POLICY................................................................................................ 29

PROMOTION POLICY ................................................................................................ 32

MOONLIGHTING POLICY .......................................................................................... 37

PARKING POLICY ...................................................................................................... 37

FATIGUE AND STRESS POLICY ................................................................................. 37

VACATION POLICY .................................................................................................... 39

SICK LEAVE ................................................................................................................ 41

MATERNITY AND PATERNITY LEAVE (FAMILY MEDICAL LEAVE) ...................... 41

PRACTITIONERS’ HEALTH COMMITTEE ................................................................ 42

NEW RESIDENTS/FACULTY ...................................................................................... 42

DISCIPLINE POLICY – DEPARTMENT OF SURGERY .............................................. 44

ACADEMIC DISCIPLINE AND DISMISSAL POLICY ................................................. 46

ACADEMIC GRIEVANCE POLICY ............................................................................. 47

PROGRAM CLOSURE/REDUCTION POLICY ............................................................ 50

CONFLICT OF INTEREST DISCLAIMER .............................................................................. 51

RESIDENT CONTRACT REVIEW ........................................................................................... 52

VACATION AND MEETING REQUEST FORM ...................................................................... 54

REQUEST FOR AUTHORIZATION TO TRAVEL.................................................................... 55

1

MISSION STATEMENT

WEST VIRGINIA UNIVERSITY

DIVISION OF PLASTIC SURGERY

As members of the West Virginia University School of Medicine Division of Plastic Surgery, it is our goal to

provide the highest quality of care to the people of West Virginia, as well as the surrounding geographical area.

To achieve this goal we direct our efforts toward three activities:

CLINICAL SERVICES:

1. Developing and maintaining excellence in specialized programs of plastic surgical care including adult

and pediatric general reconstructive surgery, breast reconstruction, cleft and craniofacial care, hand care,

lower extremity salvage, general wound care, and cosmetic surgery.

2. Developing outreach programs to enhance resident and learner education, patient access, and

convenience.

EDUCATION:

1. Providing a comprehensive training (clinical and didactic) program for physicians and learners in plastic

surgery that achieves the high standards as established by the ACGME for eventual board certification

that supports the compassionate, appropriate and effective treatment of patients with problems relevant

to plastic surgery and promotes the ethical behavior consistent with the ASPS Code of Ethics

2. Providing exposure to basic plastic surgical principles and procedures, incorporating the core values of

clinical care and surgical care to non-plastic surgery trainees.

3. Providing didactic teaching in the realm of plastic surgery to students of medicine, dentistry and other

ancillary providers.

RESEARCH:

1. Promoting involvement by members of the Division of Plastic Surgery in research and scholarly academic

activity. Residents are expected to engage with faculty and take advantage of this opportunity.

2

INTRODUCTION

Plastic Surgery is a division of the Department of Surgery at the West Virginia University School of Medicine.

The Plastic Surgery Residency is the educational arm of the Division of Plastic Surgery. This relationship is

maintained at the West Virginia University Ruby Memorial Hospital wherein we practice. Faculty members of

the Division are members of the School of Medicine. Other divisions of the Department of Surgery are General

Surgery, Bariatric Surgery, Cardiothoracic Surgery, Pediatric Surgery, Trauma/Acute Surgery, Vascular

Surgery, and Surgical Oncology.

EDUCATIONAL GOAL

The overall educational goal of the Plastic Surgery Residency is to provide an educational program with

sufficient experience in the evaluation, diagnosis and management of the plastic surgery patient to result in the

emergence of physicians with the ability for independent, competent, and moral practice of the specialty. The

West Virginia University School of Medicine Plastic Surgery Residency provides an organized, progressive

educational experience with increasing patient care responsibilities in settings with diverse patient populations

and a teaching staff with professional ability, enthusiasm and a commitment to teaching. The overall educational

goals can be met by adhering to the six (6) ACGME competencies below.

ACGME COMPETENCIES

The goal of the Plastic Surgery Residency at West Virginia University School of Medicine is to train residents

to embrace the ACGME competencies during residency as stated below.

Patient Care

Patient Care that is compassionate, appropriate and effective for the treatment of health problems and the

promotion of health. Residents must be able to competently perform all medical, diagnostic, and surgical

procedures considered essential for the area of practice

Medical Knowledge

Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and

social-behavioral) sciences and the application of this knowledge to patient care. Residents must demonstrate

knowledge of the pertinent basic science subjects, such as anatomy, physiology, pathology, embryology,

radiation biology, genetics, microbiology, pharmacology, as well as practice management, ethics, and medico-

legal topics.

Practice-Based Learning and Improvement

Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care,

appraisal and assimilation of scientific evidence, and improvements in patient care. Residents must demonstrate

the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to

continuously improve patient care based on constant self-evaluation and life-long learning. Residents are

expected to develop skills and habits to be able to meet specific goals.

Interpersonal and Communication Skills

Interpersonal and communication Skills that result in effective information exchange and teaming with patients,

their families, and other health professionals. Residents must demonstrate interpersonal and communication

skills that result in the effective exchange of information and collaboration with patients, their families, and

health professionals. Residents are expected to communicate effectively with patients, families, and the public,

as appropriate, across a broad range of socioeconomic and cultural backgrounds; communicate effectively with

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physicians, other health professionals, and health related agencies; work effectively as a member or leader of a

health care team or other professional group; act in a consultative role to other physicians and health

professionals; and maintain comprehensive, timely, and legible medical records, if applicable.

Professionalism

Professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to

ethical principles, and sensitivity to a diverse patient population. Residents must demonstrate a commitment to

carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to

demonstrate compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self

interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; and

sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender,

age, culture, race, religion, disabilities, and sexual orientation.

Systems-Based Practice

Systems-Based Practice as manifested by actions that demonstrate an awareness of and responsiveness to larger

context and system health care and the ability to effectively call on system resources to provide care that is of

optimal value. Residents must demonstrate an awareness of and responsiveness to the larger context and system

of health care, as well as the ability to call effectively on other resources in the system to provide optimal health

care. Residents are expected to work effectively in various health care delivery settings and systems relevant to

their clinical specialty; coordinate patient care within the health care system relevant to their clinical specialty;

incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as

appropriate; advocate for quality patient care and optimal patient care systems; work in inter-professional teams

to enhance patient safety and improve patient care quality; and participate in identifying system errors and

implementing potential systems solutions.

Each rotation and didactic experience will contribute to the acquisition of a given competency. It is the

responsibility of the resident to obtain these competencies by vigorous attention to patient care in and out of the

operating room, diligent study of the literature appropriate to plastic surgery, and attendance at didactic sessions.

It is the responsibility of the faculty to provide clinical and didactic resources to the residents/fellows that will

allow the residents/fellows to acquire these competencies and to evaluate their progress in doing so regularly

and take corrective action when necessary.

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SUPERVISION POLICY

Purpose: To establish a policy to ensure all residents are provided appropriate supervision while

gradually gaining autonomy and independence.

Responsibilities/Requirements

1. Lines of supervision in the Department of Surgery follow a set of guidelines, which is used

throughout all of the rotations.

2. PGY 1’s are to be supervised directly or indirectly with direct supervision immediately

available.

3. Junior (PGY 2-3) residents will supervise intern activities and also communicate with their

superiors, either upper-level residents or faculty.

4. Senior (PGY 4-6) residents will also serve in a supervisory role and will communicate with

faculty. Ultimately the decisions rest upon the faculty.

Levels of supervision are defined as:

Direct Supervision: Physically present with the resident and patient

Indirect Supervision: (Direct supervision immediately available) Supervising physician physically

within the hospital and immediately available to provide Direct Supervision.

Indirect Supervision: (Direct supervision available) Supervising physician is not physically present

within the hospital, but is immediately available by means of telephone and/or electronic modalities, and

is available to provide Direct Supervision.

Oversite: Supervising physician is available to provide review of procedures with feedback provided after

care is delivered.

The Department wants to make it clear that all residents should feel comfortable seeking help.

Only through non-judgmental interactions can residents learn effectively. Management and

patient care can seem overwhelming at times and it is the responsibility of the faculty

surgeons to ensure an environment where residents feel they have the necessary support and

can perform to their utmost abilities.

The following “SUPERVISION” guidelines have been established. It is again stressed that a resident

should never feel intimidated or belittled when asking for assistance.

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FACULTY SUPERVISION / RESPONSIBILITY GUIDELINES

Supervision of the residents/fellows shall be carried out by the teaching faculty under the direction of the

Program Director. It is the Program Director’s responsibility to see that such supervision is adequate and

appropriate to maintain both the optimal education environment and excellent quality of patient care.

Determining the level of responsibility for each resident will be the responsibility of the Program Director with

input from the teaching faculty.

The following is a list of faculty guidelines:

1. As a faculty member, you bear the ultimate responsibility for patient care and for providing the

documentation in the medical record of the care provided. These responsibilities should be exercised

without diluting the educational process.

2. Patient interaction should be real, not theoretical. Bedside, office and operating room clinical skills

should be stressed and modeled. At least some new patient presentations should occur at the bedside.

3. All patients admitted to the plastic surgery service during the week should be seen and formally staffed

with the resident on the day of admission. Patients admitted after this time should be seen and evaluated

with formal staffing with the resident the following day. If there is an acute change in the patient’s

condition during the daytime, the appropriate faculty member is to be notified immediately by the

resident. If this occurs after hours, the resident will contact the individual faculty member or the Plastic

Surgery faculty member on call at that time. For patients admitted on weekends or holidays, staffing

should occur no later than 24 hours after admission. If you are absent, residents must be aware of your

designee for patient care issues.

4. You are responsible for informing your residents of when they must contact faculty immediately relative

to the following patient care issues: end of life status change, ICU admission, need for emergency

operative intervention, etc.

5. You should plan your schedule so you will be available at all times during the day when patient care and

teaching activities are proceeding. Residents must be aware of your designee when you are out of town

or otherwise absent.

6. Feedback should be given to residents informally on a daily basis and formally at the end of the rotation

via the evaluation process. Suggestions for improvement should be made early enough for corrective

action to be attempted.

7. Regular chart reviews should be conducted. The focus should be on record completion and avoidance of

unnecessary tests and procedures, and assessment of appropriate patient care and documentation.

8. Rotating medical students and residents from other services must be included in teaching and patient care

activities. When requested, evaluations on these students and residents should be completed in a timely

manner. Plastic surgery residents must be instructed and evaluated for operative techniques during

operative procedures, as well as preoperative and postoperative care.

9. Insist that residents/fellows on your service consult the literature regularly about issues that arise in the

context of patient care. Ask them to cite the literature and share their findings with you and other team

members.

10. You are responsible for attending and participating in scheduled conferences and other didactic activities

of the Division and Department. An attendance log will be kept for program certification purposes.

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SUPERVISION

Safety of the patient as well as safety of the resident are of paramount importance. The Department of Surgery will

not compromise the safety of a patient in any way. All patient care will be supervised by the attending faculty to

varying degrees to allow for increasing autonomy and growth of the resident. It is the Department’s goal to create

a nurturing environment where residents may feel safe and secure at all times while gaining independence. A faculty

is always assigned to supervise the residents.

Ultimate responsibility resides with the attending physician who supervises all resident activities. All clinical work

is done under the supervision of an attending faculty. While the degree of supervision in any given examina tion/procedure will vary with the particulars of the event, as well as the level of training of the resident, the ultimate

responsibility for the written report created is that of the attending surgeon.

Personal responsibility and accountability. Residents and faculty are expected to hold themselves up to the highest

standards. Professionalism should be maintained at all times. It is understood that at times errors will be made, it is also understood that these errors should serve as learning points as to avoid them in the future.

Expiration. It is inevitable that at some point in a resident’s career they will have to deal with the death of a patient.

In this event the resident will notify their senior resident and/or attending immediately. Resident will be given proper training in regards to end of life issues, death pronouncements, communicating death to families and

necessary paper work. Attending faculty will be available at all times to provide support to residents following the

death of a patient.

“Ready or Not”. PGY-1 residents will participate in a supervisory evaluation at the completion of their PGY-1 year.

The evaluation will consist of video modules, patient scenarios and a written assessment regarding various procedures and patient situations. These evaluations will be scored by supervising faculty. Successful completion

of the evaluation will be necessary for the resident to be given supervisory privileges for the upcoming year.

Vital Signs. All significant change in patient vital signs or mental status will be communicated to the resident’s supervisor. Should a patient become unstable at any time, this will be communicated to the attending surgeon.

Invasive procedures. Residents will be supervised by a more senior resident or attending faculty until they are felt competent to perform that procedure independently. Hospital privileging criteria will also be followed.

Status. Any change in patient status needs to be communicated to the attending faculty. Any change in level of care

requiring a change in unit acuity, will be immediately communicated to the attending. Any change in code status

will also be relayed to the attending faculty.

Introductions & Issues. Faculty and residents will introduce themselves and inform their patients of their role in each

patient’s care. All family or patient issues or concerns will be brought first to the attention of the supervising resident.

If resolution cannot be obtained, all issues will be discussed with the attending. Issues that arise between nursing,

consulting services, ancillary care, etc. will be brought to the attention of the attending surgeon.

On call. A printed, emailed or online call schedule is sent out monthly to residents, faculty and the hospital paging

office. In the event of unforeseen circumstances, such as illness, the resident will be informed by the program director,

senior resident or program coordinator who the supervising surgeon will be. All faculty will be available during the

day and when on call via telephone and/or beeper.

Notification. Faculty will be notified of all elective admissions or transfers within 2-4 hours of arrival. All discharges

will be discussed with the attending surgeon. All changes in care plans will be communicated to the attending faculty.

If she/he is unavailable, then the program director or the chairman of the department should be contacted in order to

make a final decision on the plan and/or treatment. When the residents are called for consults in the Emergency

Department or the wards, the attending faculty will be notified immediately following the resident’s evaluation.

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EDUCATIONAL CONFERENCES

Our conference schedule is designed to cover the comprehensive curriculum for plastic surgery topics.

As part of the Department of Surgery Academic Wednesday morning, all surgical residents are relieved of all

non-emergent duties to participate in the academic morning. The Core Curriculum Conference and the Plastic

Surgery Academic Hour are dedicated periods wherein all plastic surgery faculty, all plastic surgery residents,

and rotating non-plastic surgical residents meet once weekly on Wednesdays. Attendance is mandatory and

recorded for plastic surgical staff and residents. Physician extenders, nursing, and ancillary staff are invited and

encouraged to attend as well.

1. Core Curriculum Conference The goal of the core curriculum conference is to provide the trainee with

focused instruction on a topic relevant to plastic surgery. Each Wednesday (11:00 a.m. -11:55 a.m.)

consists of a multimodality format designed to instruct the plastic surgery resident on the core topics

pertinent to general plastic surgery. A didactic review of recommended readings may be followed by a

quiz. The formatting will incorporate a Written Board question and answer session and an Oral Board

Exam type case. Topics from Plastic Surgery Indications, Operations, and Outcomes, will be used in a

two-year rotating conference schedule. Topics include the full spectrum of reconstructive and aesthetic

surgery. The conference is organized and monitored by the program director.

2. The Plastic Surgery Academic Hour: Plastic Surgery Academic Hour is held each week on

Wednesdays (5:00 p.m. -6:00 p.m.). Each month there are didactic conferences, one journal club, and

one morbidity and mortality conference.

a. Plastic Surgery Grand Rounds: The goal of grand rounds is to present a topic germane to the

practice of plastic surgery in an instructive manner so as to extend the current understanding of the

topic to residents in training, physician extenders, nurses, and ancillary providers. The resident in

training is encouraged to participate in discussion and should use the didactic hour topics as incentive

for further selected reading as these topics are covered on both in-service and the written examination

for certification in plastic surgery. A rotating schedule of topics will be managed by the program

director to assure global and salient content. Plastic surgery staff and/or field leaders will prepare 45

minute PowerPoint presentations on selected topics. A 15 minute period of discussion will occur

thereafter. The presenters will be evaluated on their presentation.

b. Journal Club: The goal of the journal club conference is to promote active review of peer reviewed

published literature. The plastic surgery staff will create a repository of recently (within the last 6

months) published papers. A plastic surgery resident will select up to 3 articles to read, prepare a

PowerPoint presentation, and present at conference. It is expected that they will facilitate discussion

by critically reviewing the papers for experimental design, execution, bias, outcomes analysis, and

conclusions. Not only the resident, but the participants are expected to gain a critical understanding

of the literature, its content, and its applicability. Plastic Surgery residents will be evaluated on their

presentations.

c. Morbidity and Mortality Conference: The goal of the morbidity and mortality conference is self-

surveillance as practicing plastic surgeons, to review best practices, to self-reflect, individually and

as a collective, and to evolve strategies for self and practice improvement. Morbidities and mortalities

from the period four weeks prior to the conference will be accrued. Residents who participated in the

listed cases will be responsible for preparing a PowerPoint presentation of the individual case. The

presentation will include salient points of the case- preoperative, intraoperative, and postoperative.

Associated photography is anticipated to enhance the discussion. A short literature review is expected

to close the presentation. The responsible attending physician will be in attendance to participate in

the presentation. Plastic Surgery residents will be evaluated on their presentation.

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EXCEPTIONS: Residents are only excused from conference:

1. with approved time off recorded by the Program Director

2. with advance notification of absence (via email) to the Program Director AND his approval for said

absence. (Christy Hayes should be copied on the note of approval from the Program Director.)

An attendance rate of 90% or higher at the Plastic Surgery conferences listed is required. During the Wednesday

academic afternoon, clinical responsibilities are waived to attend conferences. While on surgery in general

rotations, you should attend any other conferences specific to that rotation held during the week.

SKILLS LAB SESSIONS

Assigned labs are mandatory. They are monitored by the Program Director and other members of the faculty

who provide training and feedback.

The skills lab sessions are designed to be a “practice arena” for the surgical resident. These sessions allow the

resident to practice, review, and sometimes test skill and techniques to gain competence confidence.

Skills labs include:

PGY 1

1. IV insertion.

2. Suturing techniques and knot tying.

3. Chest tube insertion.

4. Central line insertion.

PGY 3

1. Basic laparoscopy skills.

The cadaveric lab sessions are designed to be a “practice arena” for the surgical resident to elevate common

tissues and flaps used in the practice of plastic surgery. These sessions allow the resident to practice, review,

and sometimes test skill and techniques to gain competence and confidence in seven procedures.

Cadaveric labs include:

PGY 3 and 4

1. Exposure of the facial skeleton.

2. Elevation of deep inferior epigastric (DIEP) flap.

3. Elevation of fibular flap.

4. Elevation of anterolateral thigh (ALT) flap.

5. Elevation of radial forearm flap.

6. Elevation of pectoralis flap.

7. Component separation.

PLASTIC SURGERY CASE LOG POLICY

The Plastic Surgery Operative Log (PSOL) is a computerized web-based log of all operating room procedures

performed in the Plastic Surgery section. The Accreditation Council for Graduate Medical Education (ACGME)

is the organization responsible for accrediting all residency training programs. The ACGME requires collection

and submission of Operating Room Data. The accuracy of the data is very important to the continued

accreditation of our program and to the assessment of eligibility of each resident for the qualifying examination

of the American Board of Plastic Surgery (ABPS). Remember that procedures performed in the emergency

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room (e.g. closed reduction of fractures, etc.) count as cases and should be recorded. It is mandatory that cases

be logged throughout the continuum of the resident’s surgical training. It is not acceptable to log the minimal

number of required cases and stop recording cases. Failure to maintain an accurate PSOL may result in

ineligibility for the qualifying examination of the ABPS.

Data collection is the responsibility of the individual resident. To enter your cases, you must go to the ACGME

web site and sign-in with your ID and password. Cases should be entered at least weekly. Operative logs are

monitored each month by the program director and Program Education Committee (PEC). If cases are not

logged and kept current, the resident will be disciplined. Surgical case logs must be completed and available for

the entire program upon graduation. No certifications will be issued until all logs are completed and the final

surgical record is signed.

Residents who have not entered their cases in a timely manner will be subject to disciplinary action. Letters may

also be placed in the resident’s file addressing the issue of non-compliance and may be discussed during

evaluations with the Program Director. The entry of case logs in a timely manner is one of the factors

contributing towards each resident’s “Professionalism” Milestone.

PLASTIC SURGERY CASE LOG DIRECTIONS

The Plastic Surgery Operative Log System (PSOL) is an internet based case log system utilizing CPT codes to

track a resident’s operative experience. The Residency Review Committee (RRC) has indexed these codes

into categories for evaluation. This program was designed to allow residents to enter procedures on a regular

basis at their convenience. Entry can be done from any PC connected to the World Wide Web at any time 24

hours a day.

1. Go to the www.acgme.org homepage. Review the Case Log System Resident User Guide Select.

The Resident Case Log System Screen will have updated information on instructions to obtain a

user ID. User’s manuals and listing of all available CPT codes are also available.

2. Once you receive an email from the ACGME with a User ID, enter the User ID and Password and

click on the “Login” button.

3. You may change your password at any time after the initial first time log in. If you would forget

your password you may contact the ACGME by clicking forgot password or reset a new password.

4. Take a few moments to review the welcome page and the manual. Depending on the level of user

access allowed, certain heading tabs may not be available.

If you need additional information or help, please contact Christy Hayes at (304) 293-7480.

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CORE REQUIREMENTS FOR INTEGRATED PROGRAM

The ACGME recently instituted core requirement minimums of particular cases for residents in the integrated

program (PGY 1-2).

Alimentary Tract/Abdominal Surgery (20 cases)

Laparoscopic/endoscopic surgical technique

Laparotomy

Abdominal wall closure

Herniorrhaphy

Bowel anastomosis or repair Other

Breast and Oncologic Surgery (20 cases)

Mastectomy

Lumpectomy

Axillary lymphadenectomy

Soft tissue extremity tumors

Trunk tumor resection

Head and neck tumor resection

Non-axillary lymphadenectomy Other

Trauma/Critical Care/Anesthesia Procedures (20 cases)

Central line placement

Tube thoracotomy

Tracheostomy

Intubation

Fasciotomy

Management of the critically ill surgical patient

Initial trauma resuscitation and stabilization

Burn resuscitation

Other

OPERATIVE MINIMUMS FOR PLASTIC SURGERY

The Resident Review Committee of the America Board of Plastic Surgery has established operative minimums

for the resident in plastic surgical training. These are effective July 1, 2014.

Reconstructive Procedures 1000 cases

Head and Neck Congenital Defects 50 cases

Primary cleft lip repair 7

Primary cleft palate repair 7

Secondary cleft lip or palate repair 7

Other congenital head/neck defects 29

Head and Neck Neoplasms 70 cases

Reconstruction with local flap 16

Reconstruction with free flap 2

11

Other including skin grafts and resection 42

Head and Neck Trauma 50 cases

Treat occlusal injury 8

Treat upper midface fracture 8

Treat nasal fracture 4

Treat complex soft tissue injury 15

Other head/neck trauma 15

Reconstructive Breast 100 cases

Breast Macromastia 24

Absent Breast

Expander/Direct implant 30

Pedicled flap 4

Free tissue transfer 4

Others including fat grafting and 38

secondary procedures

Trunk Procedures 25 cases

Treat pressure ulcer: Debride/VAC 3

Treat pressure ulcer with flap 5

Treat wound of trunk with flap 15

Other trunk 2

Total Hand/Upper Extremity 122 cases

Hand Wound Requiring Reconstruction

Primary closure 5

Skin graft 5

Reconstruction with flap 6

Amputation 7

Tendon Repair

Repair tendon 16

Release of adhesion 4

12

Tendon transfer 2

Nerve Injury

Reconstruct nerve 10

Fracture/Dislocation

Operative repair 30

Release of joint contracture 2

Treatment of Dupytren’s 2

Nerve decompression 16

Revascularization/Replantation of digit 4

Arthroplasty 3

Treat congenital deformity 2

Treat neoplasm of hand 8

Lower Extremity Procedures 25 cases

Treatment with graft 12

Treatment with local flap 9

Treatment with free tissue transfer 3

Other lower extremity procedure 1

Burns 24 cases

Burn reconstruction 16

Other burn procedures 8

Other Reconstructive Cases 534 cases

Aesthetic Procedures 150 cases

Total Head/Neck 50 cases

Facelift 10

Brow Lift 2

Blepharoplasty 20

Rhinoplasty 10

Other Head/Neck 8

Total Breast 30 cases

13

Breast Augmentation 16

Mastopexy 12

Other Breast 2

Total Body Contouring 50 cases

Brachioplasty 2

Abdominoplasty 10

Body Lift 2

Thighplasty 2

Suction assisted Lipoplasty 15

Other Body 19

Total other 20 cases

Free Tissue Transfer 20 cases

Tissue Expansion 30 cases

Liposuction 15 cases

Head and neck 5

Trunk 5

Extremity 5

Injectables 21 cases

Botox 7

Soft Tissue Fillers 7

Autologous Fat 7

Lasers 10 cases

Aesthetic 5

Reconstructive 5

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RESEARCH POLICY

The Division of Plastic Surgery recognizes research as an essential, integral component to both training and

practice. It promotes academic thought, stimulates self-assessment and evolves new treatment strategies. As

such, it is mandatory that each resident evolve and complete at least 3 research projects over the course of six

(6) years of plastic surgical training. Project completion is defined as presentation at a regional/national

meeting or submission to a medical journal. It will be expected that one project be completed by the end of

the PGY-3 year. The remaining two projects will be completed by the end of the PGY-6 year.

Residents have the opportunity to present research projects they have completed before faculty, colleagues and

students. PGY 1 and 2 residents will be required to submit an abstract for the Surgery Residents Research

forum at the Zimmermann Lectureship held in March of each year. Residents will compete at the annual

Greenbrier Resident Paper Competition at the West Virginia State American College of Surgeons Meeting

(typically held in May).

ABSITE EXAM/ PLASTIC SURGERY IN-SERVICE EXAM

Residents in integrated training years 1 and 2 are expected to participate in the annual ABSITE exam on the

scheduled day.

The Plastic Surgery in-service exam is administered annually (usually in March). All residents in training years

1 – 6, are expected to participate in the exam.

Residents not scoring in the 30th percentile or higher on the ABSITE exam or in the 30th percentile or higher

on the annual in-service exam may lose the privilege to attend off-campus meetings during the next academic

year.

USMLE/LICENSE POLICY

The WVU Department of Surgery will comply with the School of Medicine’s Bylaws and Policies regarding

the completion of the USMLE exams and application for a West Virginia State Medical License. In doing so

the following department policy will be in effect.

Overview:

All PGY 1 residents will have completed Step 1 and Step 2 CS AND CK prior to starting their intern year.

1. All PGY 1 residents will have applied for Step 3 by June 30 of their intern year.

2. All PGY 2 residents will have successfully completed and passed the USMLE Step III exam by Dec

31st of the residents PGY II year. If the resident has not passed USMLE III, by December 31st, they

must re- apply, complete and pass the exam by April of their PG 2 year. Failure to complete, will

result in immediate Academic Probation.

3. All PGY 2 residents will have applied for their WV State medical license by April of their PGY 2

year. International Medical Graduates (IMG’s) will start the process for their WV State medical

license toward completion of his/her PGY 3 year to be eligible to enter his/her PGY 4 year of

residency. Failure to apply for a WV State Medical License by April 1 of the PGY II (PGY III for

IMGs) year results in immediate Academic Probation.

4. No PGY 3 or 4 contracts for any resident will be issued until proof of application for a WV State

license is on file in the Program Coordinator’s office.

5. Doctors of Osteopathy participating in residency programs at WVU School of Medicine are also

required to be licensed by the State of West Virginia when they are first eligible. They must obtain

a license from the osteopathic board upon successful completion of their rotating osteopathic

approved internship. They must have passed all three parts of the COMLEX to qualify for this

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license. Information on rules and regulations, fees, and applications can be obtained from the Board

of Osteopathy.

Time Limit and Number of Attempts Allowed to Complete All Steps

Although there is no limit on the total number of times you can retake a Step or Step Component you have

not passed, the USMLE program recommends to medical licensing authorities that they:

1. Require the dates of passing the Step 1, Step 2, and Step 3 examinations to occur within a sevenyear

period; and

2. Allow no more than six attempts to pass each Step or Step Component without demonstration of

additional educational experience acceptable to the medical licensing authority.

For purposes of medical licensure in the United States, any time limit to complete the USMLE is established

by the state medical boards. Most, but not all, use the recommended seven years as the time limit for completion

of the full USMLE sequence. While medical schools may require students to pass one or more Steps for

advancement and/or graduation, you should understand the implications for licensure. For states that establish

a time limit for completion of all three Steps, the "clock" starts running on the date the first Step or Step

Component is passed or, in some cases, on the date of the first attempt at any Step. For definitive information,

you should contact directly the licensing authority in West Virginia. The addresses and phone numbers are

listed below in order to give you state-specific requirements.

EXPECTATIONS OF A RESIDENT’S BEHAVIOR:

1. Follow the ACGME work hour restrictions and secure your appropriate days off. It is your

responsibility to be familiar with the ACGME work hour guidelines and how to log and track them.

2. Be at work on time every day you are scheduled to work.

3. Answer your pages promptly. Allow adequate time for others to answer their pages.

4. Stay groomed and showered every day.

5. Dress: shirt/tie equivalent, or scrubs and white coat. No sweatshirts, sweatpants, jeans, shorts, etc.

WVU jackets are acceptable.

6. Round every day. See every patient on rounds. Pre-round as needed to present concise, complete,

data filled, focused exchanges with staff. Examine every patient on rounds and remove every

dressing.

7. Finish pre-rounds before Wednesday morning conferences or before going to the OR.

8. Monitor the global schedule to have an awareness of who may need help and what offers the best

learning opportunities.

9. Work a full day, even if you do not specifically have OR cases or clinic.

10. On days when you may not have cases, attend a clinic or help with surgery in other rooms.

11. Down time is a good time to read, study operative techniques, or evolve and work on research

projects before you are distracted by other obligations and duties at home.

12. “Covering” for someone means that you are responsible for all of that resident’s

duties/responsibilities: rounding, direct patient care, floor calls, ER calls, pre-op.

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CALL RESPONSIBILITIES:

1. Respond to pages quickly and courteously. It is your responsibility to remain in proximity to a phone

when you are on call.

2. It is your responsibility to maintain availability to evaluate patients within approximately 30 minutes.

You must choose your residence, maintain transportation, and arrange your personal life and child

care accordingly.

3. Respond to any patient for whom you are consulted, regardless of your assigned rotation. Questions

should be directed to the attending on-call to govern treatment expertise or hospital coverage.

4. When contacted by an outside facility pass along information that you’ve received to the ER or

admitting unit.

5. Review the patient’s complaint, lab/imaging data, and physical findings with the attending on call.

6. Every patient seen during the residency has an assigned attending. There are no patients assigned to

a “service” or “resident”. It is your responsibility to define who the attending is, document it in the

chart, and keep them informed. No patient should be admitted without the knowledge of an attending,

and no attending should be assigned when he/she is out of town.

7. Enter a history and physical (H&P) note on each patient when they are seen. This must be

documented within 24 hours at the latest.

8. Ensure proper follow-up care for patients seen in the ER in the appropriate attending’s clinic. You

may have to usher them into or through the system. It is your responsibility to learn, or investigate,

the method of follow-up for each patient within each hospital system. Do not permit a patient to get

lost to follow up.

9. Never direct questions from known patients to a local ER or to our ER unless instructed so by the

attending physician. They should be assessed for urgency and questions should be directed to the

attending on call, or to the treating attending, as appropriate.

10. Patients evaluated in the ER should be assessed and treated definitively, with a clear plan

communicated to the ER, the plastic surgery attending, and the resident assigned to the accepting

service in hospital. Patients with problems that can be treated in the ER should not be sent to clinic

to receive that same treatment. Communication should be HIPPA compliant.

11. If your plan includes going to the OR, be sure to investigate the results of labs, x-rays, the patient’s

NPO status, and the availability of the OR prior to calling the attending. Obtain consent if the patient

will go to the OR that night or the next day.

12. Take photos of every patient you see and transmit those photos to the appropriate attending via an

appropriate HIPPA compliant source.

CODE OF PROFESSIONALISM

The West Virginia University School of Medicine embraces the following Code of Professionalism amongst

all students, residents, faculty, and staff. This Code provides the foundation for proper lifelong professional

behavior. It is the expectation that this behavior will be consistently maintained at its highest level both inside

and outside of the professional training environment. This is one of the core ACGME competencies.

The nine primary areas of professionalism are defined as:

Honesty and Integrity

Honesty in action and in words, with self and with others

Does not lie, cheat, or steal

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Adheres sincerely to school values (love, respect, humility, creativity, faith, courage, integrity, trust)

Avoids misrepresenting one’s self or knowledge Admits

mistakes

Accountability

Reports to duty/class punctually and well prepared

Keeps appointments

Is receptive of constructive evaluations (by self and others)

Completes all tasks on time

Follows up on communications

Responsibility

Reliable, trustworthy, and caring to all

Prompt, prepared, and organized

Takes ownership of assigned implicit and explicit assignments

Seriously and diligently works toward assigned goals/tasks

Wears appropriate protective clothing, gear as needed in patient care

Respectful and Nonjudgmental Behavior

Consistently courteous and civil to all

Tolerates diversity in culture, country of origin, gender, sexual orientation, religious preference,

political views, age, ethnicity, and race

Works positively to correct misunderstandings

Listens before acting

Considers others’ feelings, background, and perspective

Realizes the value and limitations of one’s own beliefs, and perspectives Strives

not to make assumptions

Compassion and Empathy

Respects and is aware of others’ feelings

Attempts to understand others’ feelings

Demonstrates mindfulness and self-reflection

Maturity

Exhibits personal growth

Recognizes and corrects mistakes

Shows appropriate restraint

Tries to improve oneself

Has the capacity to put others ahead of self

Manages relationships and conflicts well

Maintains personal and professional balance and boundaries

Willfully displays professional behavior

Makes sound decisions

Manages time well

Able to see the big picture

Seeks feedback and modifies behavior accordingly

Maintains publicly appropriate dress and appearance

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Skillful Communication

Effectively uses verbal, non-verbal, and written communication skills that are appropriate to the

culture/setting

Writes and speaks with clarity at a comprehendible level

Seeks feedback that the information provided is understood

Speaks clearly in a manner understood by all

Provides clear and legible written communications

Gives and receives constructive feedback

Wears appropriate dress for the occasion

Enhances conflict management skills

Confidentiality and Privacy in all patient affairs

Maintains information in an appropriate manner

Acts in accordance with known guidelines, policies, and regulations

Seeks and reveals patient information only when necessary and appropriate

Self-directed learning and appraisal skills

Demonstrates the commitment and ability to be a lifelong learner

Accomplishes tasks without unnecessary assistance and works and values the team

Completes academic and clinical work in a timely manner

Is honest in self-evaluation of behavior, performance, skills, knowledge, strengths, weaknesses, and

limitations, and suggests opportunities for improvement

Is open to change

Completes in-depth and balanced, self-evaluations on a periodic basis.

TRAUMA COVERAGE POLICY

The Jon Michael Moore Trauma Center (JMMTC) is an ACS verified Level 1 Trauma Center. In being so,

there are several standards that are required to maintain that designation. The JMMTC operates on a tiered

trauma response system. Trauma victims deemed to require major resuscitation are designated as Priority

One (P1) traumas and require the in-house presence of an attending surgeon. Those that fall into the second

tier of response are designated Priority Two (P2) patients. P2 patients require the presence of the PGY 4/5

chief resident on arrival.

Therefore the following policy regarding this matter has been established:

1. This policy applies to weekdays from 6:00 p.m. to 6:00 a.m. and weekends/holidays 6:00 a.m.-6:00

a.m.

2. There will be a chief resident (PGY 4 or 5) in house at all times.

3. There will be a published back-up chief call schedule.

4. All off hour cases will be performed by the appropriate level resident. When possible, the PGY-3

resident will also scrub on all senior level cases with the Chief resident.

5. When the in-house chief is required to go to the OR during off hours a discussion will be held with

the operating attending prior to beginning the case. Should it be deemed that the case is of such a

critical nature that the chief resident’s absence would be a detriment to the patient; the back-up chief

will be called in from home. If the back-up chief happens to be of the same service as the operating

attending, that chief has first option to perform the case to maintain continuity of care. Otherwise, it

will be at the in-house chief’s prerogative to perform the case or pass it to the back-up chief.

Otherwise, when the in-house chief goes to the OR and a P2 Trauma is paged, the PGY-2/3 resident

will immediately report to the OR to relieve the chief resident. The chief will break scrub and report

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to the trauma. After an assessment is made and plan established, the chief will return to the OR and

the PGY- 2/3 resident will take over directing the trauma resuscitation

The back-up chief will also be available to come in from home at the request of the in-house chief should it be

felt that additional chief support is necessary.

Adapted from U. Conn Surgery Residency Manual- Resident Documentation Requirements 9/2008

Revised 5/2009

PHOTOGRAPHY POLICY

Photography is a critical component of your training and the care of your patients and the communication

thereof. It is imperative that you recognize the sensitivity of this information and that it be treated with the same

level of security as a medical record.

Outlined below are steps that you must follow with regard to patient photos:

1. Cameras/photo taking devices must be kept secure at all times.

2. Do not use your camera/photo device storage medium as you photographic repository.

3. You must use an encrypted or secure University repository for the storage of your patient images.

The departmental server is the primary location for your photographic use. All images should be

downloaded and filed. Downloads should be done daily to minimize the exposure risk.

EMAIL GUIDELINES

Email shall be considered an appropriate mechanism for official communication unless otherwise prohibited by

law. Official communication to residents by email will be sent with the full expectation that residents and fellows

will receive email and read these emails daily on work days. Residents must insure that there is sufficient space

in their accounts to allow for email to be delivered. Residents have the responsibility to recognize that certain

communications may be time-critical. Residents will not be held responsible for an interruption in their ability

to access a message if system malfunctions or other system-related problems prevent timely delivery of, or

access to, that message (e.g., power outages or email system viruses).

If a resident chooses to forward his/her mail to another email address (AOL, Hotmail, departmental server, etc.),

the resident’s campus email address remains the official destination for official university and school

correspondence.

DUTY HOUR POLICY

Beginning July 2017, Clinical and educational work hours must be limited to no more than 80 hours per

week, averaged over a four-week period, inclusive of all in-house clinical educational activities, CLINICAL

WORK DONE FROM HOME, and all moonlighting. The ACGME will enforce the 80-hour duty week for

resident physicians. It is vitally important that we comply with the regulations not only to stay within the

guidelines but also to provide a program focused on educational needs not service needs. Therefore, it is

important to have a thorough understanding of the rules, so that we can stay in compliance.

THE RULES

1. Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in-house

call activities.

2. Clinical work done from home must be counted toward the 80-hour weekly maximum.

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3. Residents must be scheduled for a minimum of one day free of duty every week (when averaged over four

weeks). At-home call cannot be assigned on these free days.

4. Maximum Duty Period of Length

a. Duty periods for residents may be scheduled to a maximum of 24 hours of continuous duty in the

hospital.

b. The program encourages residents to use alertness management strategies in the context of patient

care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between

the hours of 2200 and 0800, is encouraged.

c. Effective transfer of patient care is essential for patient safety. As such, residents are permitted to

remain on-site in order to accomplish these tasks; this period of time must be no longer than an

additional four hours.

d. Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-

house duty.

e. In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled

period of duty to continue to provide care to the single patient. Justification for such extensions of

duty are limited to reasons of required continuity for a severely ill or unstable patient, academic

importance of the events transpiring, or humanistic attention to the needs of a patient or family. In

these cases, the resident must appropriately hand over the care of all other patients to the team

responsible and document the reasons for remaining to care for the patient in question and submit

that documentation in every circumstance to the program director.

5. PGY1 residents should have 10 hours, and must have 8 hours, free of duty between scheduled duty periods.

5. Intermediate level residents should have 10 hours, and must have 8 hours, free of duty between scheduled

duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty. (Intermediate

level = Independent residency (PGY 4, 5, 6), Integrated residency PGY 5 and 6).

TRACKING DUTY HOURS

Clinical & Educational Work Hours - Revised Common Program Requirements, formally, Duty Hours, menu

item is assigned to users who are expected to track Duty Hours at some point during their educational

experience. The use of this tool is customizable by program. It may be used by residency programs to monitor

for Duty Hours violations, or by other programs for general time tracking. Trainees can use it to log the length

of time spent on a given task, during a certain activity and at a particular site. Programs may also require that

Trainees record a Supervisor for the log entry.

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Step 1: What are the details of the hours worked? Use the select lists to describe the hours worked.

Task: Select the task that best describes the hours being logged. This list is defined by your Program

Administrator. Please note that the Task selected will impact how violations calculate for the hours

logged; see your Program of Duty Hours Administrator if you have question on the task(s) you

should log.

Activity: Your program may require that you select an activity. If it is required, you will not be

able to record an entry until an activity is selected.

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If the scheduled activities only box appears and is checked, then the select box will be limited to those

activities that appear on your schedule 60 days in the past and 30 days in the future. You may uncheck

this box to re-populate the select box with all available activities.

Please note, when the Activity field precedes the Site field, then your Activity selection will filter the

list of available sites. The reverse is also true - if the Site field precedes the Activity field, then your

Site selection will filter the list of available activities.

Site: Optional field - not all programs track Sites. If the field is included, select the site for the hours

being logged. If the scheduled sites only box appears and is checked, then the select box will be

limited to those sites that appear on your schedule 60 days in the past and 30 days in the future.

Please note, when the Site field precedes the Activity field, then your Site selection will filter the list

of available activities. The reverse is also true - if the Activity field precedes the Site field, then your

Activity selection will filter the list of available sites.

Choose a Supervisor: Optional field - not all programs use Supervision. Select the individual who

supervised you during the time logged.

Enter a comment about the shift (optional): You may include a comment with the log entry that

will be available to supervisors and administrators.

Start and End Time: Indicate the length of time being logged. If you enter a shift length that

exceeds the length permitted for your training rank and program, you may be prompted by one or

more questions. When the shift length form displays, you must answer each question and enter a

comment before you can save the entry.

Step 2: What calendar day(s) do the details entered apply to? Use the date-pick calendar to select the days

on which you want to log hours.

Select Dates calendar: Once you have described the details of the log entry using the fields

described above, use the Select Dates calendar to apply those details to applicable dates. As you

select dates, the log details will populate in the Selected Dates list and on the calendar below.

Calendar Options and Explanations

Legend: Log entries are color-coded by Task Type; these colors are described in the legend. All

checked types will display in the calendar. You may uncheck types to filter the calendar entries

by task.

Supervision: There are 3 types of supervision available in E*Value: None, Active, and Passive.

None - If Supervision is not used, your entries will automatically be accepted and they

will display the green check mark icon.

Active - If supervision is set to Active, then the selected supervisor will need to validate

the entry before it is accepted. The entry will display a red exclamation icon until the

hours are validated. Once it is validated, it will display the green check mark icon.

Depending on your program setup, you may not be able to edit an entry that has already

been validated.

Passive - If supervision is set to Passive, then the entry will default to accepted once it is

logged. The supervisor will be notified that an entry was made. If the supervisor agrees

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with the entry, no action will be taken. If the supervisor disagrees with the entry, then the

entry will be set to unapproved.

Duty Hours calendar: The calendar will populate with entries logged from the Select Dates calendar. You

may also apply details from the select box above by clicking on a date in this calendar. To edit an entry on the

calendar, click on the linked task.

Shift Violation Questions

You may be prompted to answer questions about shifts that could be potential Duty Hours violations.

Shift Length Violations

When a shift is logged with a length that exceeds the permitted shift length for your training rank, but it is

within the allotted time for transitioning patient care, a popup window may prompt you to indicate whether

or not you were assigned new patient care responsibilities during this time:

Depending on your answer and your program's setup, you may be prompted to answer additional questions

and enter a comment about the shift. Shifts logged that exceeded the permitted shift length due to transitioning

patient care only will display on the Duty Hours calendar with a T:

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Shift Break Violations

If you log consecutive shifts separated by a length of time that is less than the required shift break for your

training rank and program, then you may be prompted to answer a comment about the shortened shift

break:

Verifying Shifts Imported from Schedule

Programs have the option to import shifts from E*Value's Shift Scheduling tool to their trainee's Duty Hours

calendars. If your program chooses this option, those shifts will display on your Duty Hours calendar as

"Unverified." After the actual shift occurs, you should modify the hours, if necessary, and verify that you

worked that shift. Click the uv link to verify the shift:

If the actual shift exceeds the permitted Shift Length for your program and Rank, then you will be prompted

to answer any Shift Length Violation questions that have been defined by your program.

Editing an Entry

To edit an existing entry, click the task name on the calendar in the lower portion of the screen. The Edit

Duty Hours Entry box will display. Please note, programs that track Supervisors for hours logged have the

option to lock entries once they have been validated by a supervisor. If your program is configured this way,

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you may not be able to edit entries that appear with the green check mark icon. The following will display

when you click on the entry:

Reviewing Statistics and Violations

You can click the View Stats Reports link in the lower-left corner of the logging screen to preview your

Duty Hours Statistics and Violations.

The Duty Hours Trainee Reporting window will open:

Your statistics for the selected date range will display. Any violations that occurred during the period will

display by type, as shown in the example below:

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Email Notices and Reminders

Please note that your program may send email notices reminding you to log your hours. This is configured

by program, but in most cases you will continue to receive these reminders until hours are logged.

Duty Hours Violations:

Failure to log Duty Hours 2 weeks within a single month constitutes one violation. Two violations over 2

months will place the resident on Administrative leave.

Two occurrences of Administrative Leave over 6 months lead to Academic Probation. Any subsequent

violation of Duty hour recording in that year results directly in Probation.

Each resident will log his or her hours into the E*value, online system at www.e-value.net. You will be given

a login name and password. If you should forget your name or password please contact the Residency

Manager, Christy Hayes, (304) 293-7480.

Weekly periods run from Monday through Sunday. The hours are to be logged in upon completion of their

Sunday shift. The hours will be retrieved by the program on Monday and compiled. Off-service residents

should also record their hours.

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AT-HOME CALL

Time spent in the hospital by residents on at-home call must count towards the 80 hour maximum weekly hour

limit.

The frequency of at-home call is not subject to the every third night limitation, but must satisfy the requirement

for one-day-in-seven free of duty, when averaged over four weeks. At-home call must not be so frequent or

taxing as to preclude rest or reasonable personal time for each resident.

Residents are permitted to return to the hospital while on at home call to care for new or established patients.

Each episode of this type of care, while it must be included in the 80 hour weekly maximum, will not initiate

a new “off duty period”.

TRANSITIONS OF CARE

I. Rationale

To assure continuity of care and patient safety, ACGME requires a minimum number of patient care

transitions, a structured and monitored handoff process, training for competency by residents in handoffs,

and readily available schedules listing residents and attending physicians responsible for each patient's care.

In addition to resident-to-resident patient transitions, residents must care for patients in an environment that

maximizes effective communication among all individuals or teams with responsibility for patient care in

the healthcare setting.

II. Policy

A. Each training program should review call schedules at least annually to minimize transitions in

patient care within the context of the other duty hour standards. Whenever possible, transitions in care

should occur at a uniform daily time to minimize confusion. Should changes in the call schedule be

necessary, documentation of the process involved in arriving at the final schedule should be included in

the minutes of the annual program review.

The dedicated Department of Surgery sign-out time each weekday (M-F) is from 5:30-6:30 pm.

Call Schedules are made monthly and done so in a manner so that transitions of care are kept to as

much of a minimum as possible.

Department of Surgery call schedules are available within the Connect call system. These include service

specific as well as attending staff contact information.

B. Each residency training program that provides in-patient care is responsible for creating an

electronic patient checklist utilizing an appropriate template and is expected to have a documented process

in place to assure complete and accurate resident-to-resident patient transitions. At a minimum, key

elements of this template should include:

Patient name

Age

Room number

ID number

Name and contact number of responsible resident and attending physician Pertinent

diagnoses

Allergies

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Pending laboratory results and X-rays

Overnight care issues with a "to do" list including follow up on laboratory and X-rays

Code status

Other items may be added depending upon the specialty.

C. There must be a structured face-to-face, phone-to-phone, or secure intra-hospital electronic handoff

that occurs with each patient care transition. At a minimum this should include a brief review of each patient

by the transferring and accepting residents with time for interactive questions. All communication and

transfers of information should be provided in a manner consistent with protecting patient confidentiality.

The Department of Surgery instituted a “Protected Time” between 5:30-6pm each day for the

Handoff/Sign-out of patient care to the Night Team. The On Call” paging system reads: “Please hold

Non-Urgent Pages between 5:30-6pm for Surgery Sign-out”.

All surgery residents will be excused from the floors and the operating room during the

handoff/transition time period. The nurse managers of the floors have been notified to hold all non-

urgent pages and calls until after this time.

Once a month a faculty member is assigned to moderate and document the sign-out process of the surgery

teams.

D. Each training program is responsible for notifying the hospital telephone operators about its call

schedule so that the entire health care team (staff physicians, residents, medical students, and nurses) know

how to immediately reach the resident and attending physician responsible for an individual patient's care.

E. Each training program is responsible for assuring its trainees are competent in communicating with

all caregivers involved in the transitions of patient care. This includes members of effective inter-

professional teams that are appropriate to the delivery of care as defined by their specialty residency review

committee. Methods of training to achieve competency may include annual review of the program-specific

policy by the program director with the residents, departmental or GME conferences, or review of available

on-line resources. Programs must include the transition of care process in its curriculum. Residents must

demonstrate competency in performance of this task. Programs must develop and utilize a method of

monitoring the transition of care process including evaluation of the residents, as well as the process, using

E*Value, and must update this method as necessary.

III. GME Monitoring and Evaluation

A. To evaluate the effectiveness of transitions, monitoring will be performed using information

obtained from electronic surveys in E*value. Each resident must be evaluated, at minimum, once

per year, to assess their ability to effectively and safely hand off their patients. For the first year

resident, best practice would necessitate this evaluation to occur early in the academic year so

problem areas may be addressed quickly.

B. Programs must have residents and faculty complete an evaluation, at least annually, on the

effectiveness of the handoff system. This will be done via questions on the standard program

evaluation for both residents and faculty. In addition, programs may choose to add specialty specific

questions to gain more detailed information.

C. Monitoring and assessment of the Handoff process by the program must be documented in

the Annual Program Review. In addition, during the annual meeting between the Program Director,

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the Department Chair, and the DIO, this documentation will be reviewed to confirm the Transition

of Patient Care process is in place and being effectively taught, monitored, and evaluated by the

program. Deficiencies in this area will result in an in-depth special program review of your

program.

GMEC approved: September 9, 2011

GMEC modified: September 13, 2013

EVALUATION POLICY Residents are evaluated on a continuous basis and, as an academic institution, evaluations are extremely

important. They provide much-needed and required feedback on the performance of the resident on each

particular service. If a specific problem occurs, it will be addressed in a timely manner. Less severe problems

are discussed in the evaluation meeting between the Program Director and the resident.

Formal evaluation of each resident will be performed using the following evaluation tools.

1. Faculty, physician extender, peer, patient, and nursing staff evaluation forms from each rotation

(360 evaluation process)

2. ABSITE score

3. Plastic Surgery In-Service scores

4. The Plastic Surgery Milestone Evaluations (six ACGME Competencies)

5. Attendance and participation in conference

6. Resident operative experience tracking (Record Keeping of Cases)

7. Duty Hour log (Record Keeping of Hours)

8. Clinical Competency Committee Meetings (quarterly for each resident)

Formal evaluation of each rotation will be performed using the following evaluation tools.

1. Rotation evaluation

2. Faculty assessment

For residents, completion of evaluations in a timely manner is a key factor contributing to the “Professionalism”

milestone.

An evaluation is completed for each resident at completion of each rotation. Any negative evaluations will be

brought to the attention of the Program Director, who will bring it to the attention of the resident. Measures to

correct the problem will be addressed.

Resident performance review is performed for each 2 times a year by the program director and four (4) times a

year by the Clinical Competency Committee (CCC). The resident has access to the evaluations at all times

through the E*value system.

The resident will meet with the Program Director on a semi-annual basis to discuss his/her progress in the

program. These meetings take place in January and May. All rotation evaluations will be reviewed with the

resident and if there is an area of concern, the program director may have additional meetings if required.

Each year all residents participate in the American Board of Surgery In-Service Training Examination

(ABSITE) and the Plastic Surgery In-Service Exam given nationally by all Surgery departments to evaluate

each individual’s progress. These examinations are designed to assess the residents’ fund of knowledge.

All evaluations are kept as part of the resident’s portfolio. Residents are urged to review their portfolios monthly

and sign all evaluation forms. Residents may have access to their academic files at any time. The Program

Director is available for discussion and the residents are encouraged to seek guidance for any perceived

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difficulty or problem. The residents routinely and anonymously complete confidential evaluations of their

various rotations, the program and the surgical faculty.

The following are a list of evaluations used to assess the resident and used for the resident to assess the program.

Plastic Surgery Transition of Care Evaluation Completed each rotation

An assessment of the ability of the resident to transfer patient care in a safe, effective, efficient manner.

Performed by the program director at a minimum of once during each rotation during PGY 1 and 4, and if

warranted otherwise. A component of the 360 Evaluation.

Plastic Surgery Physician Extender Evaluation Completed each rotation

An assessment of the resident that includes medical knowledge, transfer of patient care, teaching, progress,

professionalism, and care coordination. Performed at the end of each rotation by physician extenders that

regularly engage the resident. A component of the 360 Evaluation.

Plastic Surgery Nursing Evaluation Completed each rotation

An assessment of the resident that includes medical knowledge, transfer of patient care, teaching,

professionalism, and care coordination. Performed at the end of each rotation by clinic nurses that regularly

engage the resident. A component of the 360 Evaluation.

Plastic Surgery Peer to Peer Evaluation Completed each rotation

An assessment of the resident that includes transfer of patient care, teaching, progress, professionalism, and

care coordination. Performed at the end of each rotation by resident peers that regularly engage the resident. A

component of the 360 Evaluation.

Plastic Surgery Resident Evaluation of Rotation Completed each rotation

An assessment of the overall rotation training experience to allow for timely feedback. Performed at the end of

each rotation by the resident.

Plastic Surgery Resident Evaluation of Faculty Completed each rotation

An assessment of the faculty who engaged the resident during the rotation including teaching ability,

commitment to educational program, clinical knowledge, professionalism, and scholarly activities. Performed

at the end of each rotation by the resident.

Plastic Surgery Resident Surgery In General Review Completed July PGY 1 2

An assessment of the first two years of the integrated plastic surgery training program. The intent is to evaluate

the surgery in general experience for utility of individual rotations, specific and overall educational value,

educational content, and attainment of designated educational goals and objectives. Performed by the resident

at completion of PGY 2.

Plastic Surgery Exit Interview Completed July PGY6

An assessment of the resident’s plastic surgical training experience. The intent is to evaluate the plastic surgery

training experience for utility of individual rotations, specific and overall educational value, educational content,

and attainment of designated educational goals and objectives. Performed by the resident at completion of PGY

6.

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Plastic Surgery Milestone Evaluations Completed each rotation

An assessment of resident performance during each rotation that evaluates each of the six clinical competencies.

The Plastic Surgery Milestone Project, a joint initiative of the Accreditation Council for Graduate Medical

Education and The American Board of Plastic Surgery, Inc. is the framework for the evaluation. The milestones

represent knowledge, skills, attitudes and other attributes for each of the six competencies organized in a

framework from less to more advanced, and are targets for resident performance as the resident moves from

entry through graduation. Performed at the end of each rotation by clinical physicians that regularly engage the

resident.

Patient Satisfaction Surveys Completed each rotation

An assessment of the resident that includes medical knowledge, communication skills, professionalism, and

care coordination. Performed at the end of each rotation by patients for whom the resident has cared. A

component of the 360 Evaluation.

Plastic Surgery Resident Self Evaluation Completed quarterly

An assessment of the resident that involves a self-assessment of communication and operative skills. Performed

quarterly by the resident. A component of the 360 Evaluation

Audit of Patient Encounter Completed quarterly PGY1 & 4

An assessment of the ability of the resident to complete and document an effective and efficient patient

encounter including history interview, physical examination, medical decision making and plan, and record

keeping. A chart audit is performed by the program director at a minimum of once quarterly during PGY 1 and

4, and if warranted otherwise.

Observation of Patient Encounter Completed quarterly PGY1 & 4

An assessment of the ability of the resident to complete an effective and efficient patient encounter including

history interview, physical examination, professionalism, medical decision making, and record keeping. The

program director directly observes a patient encounter at a minimum of once quarterly during PGY 1 and 4, and

if warranted otherwise.

Operative Skills Focused Assessment Completed quarterly

An assessment of the performance of the resident during a specific operative procedure in which he participated.

Assessment includes appropriateness of surgical indication, tissue handling, use of assistants, use of

instruments, observation of sterility, economy of motion, knot tying, understanding of flow, and team dynamics.

Performed by the staff surgeon who directly worked with the resident. This assessment may be completed at

any time during the six years of residency.

Research Progress and Evaluation Completed June and December

A one-on-one interview between the resident and program director twice yearly for the specific

purpose of keeping research on task. Research and quality improvement projects are discussed including

progress, challenges, mentor relationships, goals, and outcomes (posters, presentations, publications).

Recommendations and short and long term goals are outlined.

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Plastic Surgical Skill Evaluation Completed PGY 4, 5, and 6

An assessment of the ability of the resident to perform nine specific, frequently encountered plastic surgery

procedures- three per year, each with graduated complexity. The program director and resident will coordinate

so that the resident can be directly observed during the execution of each procedure. Assessment will include

pre-operative preparation, justification of selected procedure, attention to safety, surgical marking/positioning,

knowledge of surgical steps, handling of tissue, use of assistants, temperament, handling of complications,

immediate postoperative result, dressing application, and CPT coding. Performed quarterly PGY 4, 5, 6.

Evaluation of Presentation Completed quarterly PGY4, 5, 6

An assessment of the ability of the resident to present a topic in a public forum including organization,

communication skills, audiovisual materials, content, and audience engagement. Performed at the end of the

presentation by audience participants.

Quality Improvement Review Completed quarterly PGY4, 5, 6

An assessment of the ability of the resident to present a topic in a public forum including organization,

communication skills, audiovisual materials, content, and audience engagement. Performed at the end of the

presentation by audience participants

Program Semi-Annual Review Completed December

A one-on-one interview between the resident and program director midway through the academic year. The

year to date is discussed including medical licensure, state licensure, portfolio status, in-service scoring, duty

hours, surgical log status, research and quality improvement project status, clinical competency committee

review and recommendations, wellness, resident concerns, and program director concerns and

recommendations. A recommendation of continuance/discontinuance will be made and endorsed by both the

program director and resident.

Program Annual Review Completed June

A one on one interview between the resident and program director at the end of the academic year. The year is

discussed including medical licensure, state licensure, portfolio status, in-service scoring, duty hours, surgical

log status, research and quality improvement project status, clinical competency committee review and

recommendations, wellness, resident concerns, and program director concerns and recommendations. A

recommendation of continuance/discontinuance will be made and endorsed by both the program director and

resident.

PROMOTION POLICY

Criteria for advancement

Residents are expected to complete all items listed in this section before advancing to the next level.

PGY 1 advancing to PGY 2

1. identify the purpose of clinic visit / hospital admission

2. obtain a thorough and purposeful patient history

3. perform an accurate and comprehensive physical exam

4. develop an appropriately ordered, reasonable differential diagnosis (3 or more) for presenting

problem

5. develop a working diagnosis

6. recognize when a patient is sick (i.e. move patient to appropriate level of care, be able to

troubleshoot)

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7. order appropriate labs/tests for the presenting problem

8. prescribe medication appropriately

9. show ability to retrieve data well (key x-rays, studies, interventions, etc.)

10. demonstrate ability to obtain consults and explain to consultants the patient’s course and issues

11. show ability to organize and prioritize in daily ward care

12. display abilities during in-house call, including communicating any issues about patients overnight,

so that faculty are confident in resident’s abilities

13. demonstrate proper informed consent for PGY 1 level procedures: central lines, chest tubes, arterial

lines, breast biopsies, hernias

14. display legible and organized documentation with a completed problem list and plan for each patient

15. communicate effectively with team to keep them informed of daily patient management issues

16. demonstrate appropriate skills in mentally preparing for surgery (reading up on cases and thinking

about the surgical technique prior to surgery)

17. recognize limitations and seek help appropriately

18. accept feedback well regarding operative technical skills

19. introduce self to patient and address patient with appropriate title

20. demonstrate cultural sensitivity (caring for patients regardless of gender, race, religion, or creed) in

the work environment

21. learn from experience

22. document all procedures performed during PGY 1 year including: central lines, arterial lines, chest

tubes, DPLs, intubations, FAST exams

23. attend > 80% of conferences, specifically M&M, Didactic Hour, and Journal Club

24. demonstrate a commitment to carrying out professional responsibilities including:

a. being on time to conferences/rounds/appointments

b. dressing professionally outside the OR

c. documenting duty hours weekly

d. completing dictation appropriately and timely

e. complying with departmental policies

f. completing evaluations within 14 days of receiving them

g. attending 1 clinic per week

25. demonstrate efficient and thorough patient sign-out

26. perform well in a team environment

27. teach medical students effectively (on the moment-to-moment things)

28. utilize medical databases (Up-to-Date, Pub Med, etc.) to gather best medical evidence

29. complete intern lab skills curriculum

30. complete remediation by May 1 when scoring below 40% on the ABSITE

PGY 2 advancing to PGY 3

1. identify and work up a clinical problem appropriately

2. communicate a working diagnosis to the patient

3. discuss surgical and non-surgical treatment alternatives appropriately with patient

4. discuss appropriate follow-up and /or discharge planning with patient

5. show ability to organize and prioritize in emergent situations

6. show ability to organize and prioritize in daily ward care

7. accurately interpret radiologic exams (i.e. CT scans or plain films)

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8. order appropriate labs/tests for the presenting problem

9. utilize medical databases (Up-to-Date, Pub Med, etc.) to gather best medical evidence

10. display abilities during in-house call, including communicating any issues about patients overnight,

so that faculty are confident in resident’s abilities

11. demonstrate proper informed consent and document all PGY 2 level procedures including: open

hernia repair, lap chole, amputation, appendectomy, bowel resection & anastomosis, and fascial

closure

12. display legible and organized documentation with a completed problem list and plan for each patient

13. communicate effectively with team to keep them informed of daily patient management issues

14. demonstrate appropriate skills in mentally preparing for surgery (reading up on cases and thinking

about the surgical technique prior to surgery)

15. recognize limitations and seek help appropriately

16. accept feedback well regarding operative technical skills

17. demonstrate efficient and thorough patient sign-out

18. teach medical students effectively (on the moment-to-moment things)

19. begin to evaluate the literature for presentations

20. introduce self to patient and address patient with appropriate title

21. demonstrate cultural sensitivity (caring for patients regardless of gender, race, religion, or creed) in

the work environment

22. learn from experience

23. attend > 80% of conferences, specifically M&M, Didactic Hour, and Journal Club 24. demonstrate

a commitment to carrying out professional responsibilities including:

a. being on time to conferences/rounds/appointments

b. dressing professionally outside the OR

c. documenting duty hours weekly

d. completing dictation appropriately and timely

e. complying with departmental policies

f. completing evaluations within 14 days of receiving them

g. attending 1 clinic per week

26. pass USMLE Step III examination

27. maintain current BLS, ACLS, and ATLS certification

28. complete remediation by May 1 when scoring below 40% on the ABSITE

PGY 3 advancing to PGY 4

1. identify and work up a clinical problem appropriately

2. communicate a working diagnosis to the patient

3. discuss surgical and non-surgical treatment alternatives appropriately with patient

4. discuss appropriate follow-up and /or discharge planning with patient

5. show ability to organize and prioritize in emergent situations

6. show ability to organize and prioritize in daily ward care

7. accurately interpret radiologic exams (i.e. CT scans or plain films)

8. order appropriate labs/tests for the presenting problem

9. independently manage patients in the ICU

10. utilize medical databases (Up-to-Date, Pub Med, etc.) to gather best medical evidence

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11. display abilities during in-house call, including communicating any issues about patients overnight,

so that faculty are confident in resident’s abilities

12. demonstrate proper informed consent and document all procedures through PGY 3 level including:

open hernia repair, lap chole, amputation, appendectomy, bowel resection & anastomosis, and fascial

closure

13. display legible and organized documentation with a completed problem list and plan for each patient

14. communicate effectively with team to keep them informed of daily patient management issues

15. demonstrate appropriate skills in mentally preparing for surgery (reading up on cases and thinking

about the surgical technique prior to surgery)

16. recognize limitations and seek help appropriately

17. accept feedback well regarding operative technical skills

18. demonstrate efficient and thorough patient sign-out

19. teach medical students effectively and mentor PGY 1 and 2 residents (on the moment-to-moment

things)

20. evaluate the literature for presentations

21. introduce self to patient and address patient with appropriate title

22. demonstrate cultural sensitivity (caring for patients regardless of gender, race, religion, or creed) in

the work environment

23. learn from experience

24. attend > 80% of conferences, specifically M&M, Didactic Hour, and Journal Club 25. demonstrate

a commitment to carrying out professional responsibilities including:

a. being on time to conferences/rounds/appointments

h. dressing professionally outside the OR

i. documenting duty hours weekly

j. completing dictation appropriately and timely

k. complying with departmental policies

l. completing evaluations within 14 days of receiving them

m. attending 1 clinic per week

27. maintain current BLS, ACLS, and ATLS certification

28. complete remediation by May 1 when scoring below 40% on the ABSITE

PGY 4 advancing to PGY 5

1. obtain a thorough and purposeful patient history

2. perform an accurate and comprehensive physical exam

3. use medications and diagnostic studies appropriately

4. record complete and accurate information

5. communicate effectively with residents, faculty, and nursing to ensure optimal patient care

6. obtain consultations from appropriate services for elective care of patients

7. demonstrate reliability and responsibility for patient care

8. refer patients to appropriate practitioners and agencies

9. use available information technology to obtain and manage information

10. effectively communicate with patients and families a treatment plan including appropriate informed

consent for operation

11. effectively counsel and educate patients and families to the risks and benefits of surgery as well as

expectation and alternatives to surgery

12. describe treatment plans clearly to other physicians and record it in textural and other forms

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13. facilitate the learning of students, residents and other health care providers

14. lead a surgical team to perform excellent patient care

15. obtain the technical skills needed to perform specified procedures encountered in each rotation

16. obtain the medical knowledge to solve patient care problems encountered in each rotation

17. judge when to seek available assistance from attending

18. access appropriate assistance within the health care system for coordination and management of

ongoing care

19. prepare for cases by reading on surgical technique/anatomy, reviewing patient chart, and looking at

patient films prior to start time

20. maintain professional, responsive, and mutually respectful working relationships with peers,

subordinates, and all levels of patient care staff

21. attend weekly clinic of the various faculty members

22. complete medical records promptly

23. document duty hours on a weekly basis

24. document all procedures in the ACGME case logs website

25. participate in weekly conferences (for full duration)

26. deliver a comprehensive one hour didactic conference on a selected topic

27. complete evaluation forms for faculty and rotation in a timely manner

28. perform microsurgical vascular anastomosis and neural repair on a cadaver

29. complete goals and objectives (technical and cognitive) for each of the rotations within the first year

behave in a manner consistent with the values of WVU

30. submit at least one medical paper (case report, chapter, etc.) for publication.

31. complete summation interview including logging of all cases

32. successfully achieve competency in Medical Knowledge, Patient Care, Professionalism,

Interpersonal Communication Skills, Practice-based Learning and Improvement, and Systems-based

Practice

PGY5 advancing to PGY6

1. advocate for patients within the health care system

2. practice cost-effective health care and resource allocation without compromising quality of care

3. describe patient care actions in CPT language in an accurate and ethical fashion

4. appraise and assimilate evidence from scientific studies related to his/her patients' health problems

5. accurately assess the performance of junior residents, rotating residents from other services, and

medical students

6. provide prompt consultations upon request

7. complete goals and objectives (technical and cognitive) for each of the rotations

8. complete summation interview including logging of all cases

9. achieve a score of ≥ 30th percentile on the plastic surgery in-service examination

PGY6 to graduation

1. assess aesthetic patients for their suitability for operation and choosing an appropriate operative or

non-operative approach

2. describe patient care actions in CPT language in an accurate and ethical fashion

3. evaluate the accuracy, validity, and usefulness of a publication or presentation on plastic surgery 4.

achieve a score of ≥ 30th percentile on the plastic surgery in-service examination

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COMPLETION OF RESIDENCY

Residents will not receive certification of completion and eligibility for the qualifying examination for the

American Board of Plastic Surgery until:

1. All dictations are complete

2. Plastic Surgery Operative Log is up-to-date and complete

3. Exit Interview with Program Director is complete

4. Duty Hours are up-to-date

MOONLIGHTING POLICY

Moonlighting is NOT permitted for plastic surgery residents. The Division of Plastic Surgery feels

activities outside the educational program must not interfere with the resident’s performance nor must they

compete with the opportunity to achieve the full measure of the educational objectives of the residency.

The faculty feels that a surgical residency is a demanding and rigorous experience. It is felt that moonlighting

also interferes with the resident’s opportunities for study, relaxation, rest and a balanced life style.

PARKING POLICY

Here are some helpful hints and information that address many of the more common questions we receive

regarding parking.

Do not use patient/visitor parking lots. This is one of the most egregious parking offenses an employee can

commit, with the exception of parking illegally in a handicapped space. This practice does not reflect the

patient first values of our organization.

Do not park illegally anywhere on WVUH property. There are always permit parking spaces available in

resident lots B-1 and E. If you cannot find a space, approach one of the Security Officers and they will direct

you to a space.

If you have more than one vehicle and you forget to transfer your permit, please obtain a staff temporary permit,

good for one day. You will need to obtain the permit from the Security office.

If you lose your parking permit, please see the Security Office for replacement. There is a fee to replace a lost

permit.

If you have been towed, you will need to contact the WVUH Security Office or a security officer.

FATIGUE AND STRESS POLICY

Symptoms of fatigue and stress are normal and expected to occur periodically in the resident population, as it

would in other professional settings. Not unexpectedly, residents may experience some effects of inadequate

sleep and stress. The West Virginia University Department of Surgery has adopted the following to address

resident fatigue and stress:

Residents and Faculty are required to complete a Sleep & Fatigue CBL Course in SOLE.

Recognition of resident excess fatigue and stress is important. Signs and symptoms of resident fatigue and stress

may include but are not limited to the following:

1. Inattentiveness to details

2. Forgetfulness

3. Emotional instability

4. Irritability

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5. Increased conflicts with others

6. Lack of proper hygiene

7. Difficulty with novel tasks

8. Multitasking

9. Impaired awareness

Response:

The symptoms of resident excess fatigue and stress may present in patient care settings or in non-patient care

settings such as lectures and conferences. In patient care settings, patient safety, as well as the personal safety

and well-being of the resident mandates an immediate and proper response sequence. In non-patient care

settings, responses may vary depending on the severity and demeanor of the resident's appearance and perceived

condition.

The following is intended as a general guideline for those recognizing or observing excessive resident fatigue

and stress in either setting:

Patient Care Settings

In the interest of patient and resident safety, identifying that a resident is exhibiting evidence of excess fatigue

and stress requires the attending or senior resident to consider immediate release of the resident from any

further patient care. The attending clinician or senior resident should privately discuss his/her concern with

the resident, attempt to identify the reason for excess fatigue and stress, and estimate the amount of rest

that will be required to alleviate the situation. In all situations, the attending clinician must attempt to notify

the chief/senior resident on-call, residency manager, residency director, or department chair, respectively of

the decision to release the resident from further patient care responsibilities.

If excess fatigue is the issue, the attending clinician must advise the resident to rest for a period for relief

of fatigue before operating a motorized vehicle. This may mean that the resident should first sleep in the

on-call room. The resident may go to the Emergency Room front desk and ask that they call for security,

a cab or someone else to provide transportation home.

If stress is the issue, the attending, after privately counseling the resident, may opt to take immediate action

to alleviate the stress. If, in the opinion of the attending, the resident stress has the potential to negatively

affect patient safety, the attending must immediately release the resident from further patient care

responsibilities at that time. In the event of a decision to release the resident from further patient care

activity notification of program administrative personnel shall include the chief/senior resident on call,

residency manager, residency director or department chair, respectively.

A resident who has been released from further patient care because of excess fatigue and stress cannot appeal

the decision to the attending.

A resident who has been released from patient care cannot resume patient care duties without permission

from the program director.

The residency director may request that the resident be seen by the Faculty and Staff Assistance Program

(FSAP), (304) 293-5590, prior to return to duty.

Allied Health Care Personnel

Allied health care professionals in patient service areas will be instructed to report observations of apparent

resident excess fatigue and/or stress to the observer's immediate supervisor who will then be responsible for

reporting the observation to the respective program director.

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Residents

Residents who perceive that they are manifesting excess fatigue and/or stress have the professional

responsibility to immediately notify the attending clinician, the chief resident, and the program director

without fear of reprisal.

Residents recognizing resident fatigue and/or stress in fellow residents should report their observations and

concerns immediately to the attending physician, the chief resident, and/or the residency director.

Following removal of a resident from duty, in association with the chief resident, the residency director must

determine the need for an immediate adjustment in duty assignments for remaining residents in the program.

Subsequently, the residency director will review the residents' call schedules, work hour time cards, extent

of patient care responsibilities, any known personal problems and stresses contributing to this for the

resident.

For off-service rotations, the residency director will notify the program director of the rotation in question to

discuss methods to reduce resident fatigue.

In matters of resident stress, the residency director will meet with the resident personally as soon as can be

arranged. If counseling by the residency director is judged to be insufficient, the residency director will refer

the resident to the FSAP (Faculty and Staff Assistance Program) for evaluation.

If the problem is recurrent or not resolved in a timely manner, the residency director will have the authority

to release the resident indefinitely from patient care duties pending evaluation by FSAP.

VACATION POLICY

The American Board of Plastic Surgery now requires all vacation, meeting and interview days be recorded

on the application for the qualifying exam. A minimum of 48 weeks of full time surgical experience is

required per residency year.

1. Interns (PGY 1) will receive 3 weeks of vacation per year.

2. Residents (PGY 2-6) will receive 3 weeks of vacation per year.

3. Residents will submit a request for their proposed vacation dates to the program director for the year,

prior to July 31st. Alternate dates should be included.

4. Any resident not submitting requested dates by July 31st, will be assigned their vacation dates by the

program director.

5. All attempts will be made to accommodate each resident’s first choice.

6. NO vacations will be permitted in July, the last 2 weeks of June, the last two weeks of December or

the first week of January. (Rare exceptions may be granted at the program director’s discretion)

7. All vacations must be taken in one-week intervals. Exceptions will be made on a case-by-case basis

in consultation with the program director.

8. Only one week of vacation will be allowed per month per resident.

9. Only one week of vacation will be allowed per rotation per resident.

10. A week constitutes 7 consecutive days.

11. Each service will share an equal burden of vacation absences by residents. Night Float will be an

exception to this rule, as no vacations will be permitted during the night float rotation.

12. Only one resident per PGY year may be gone at the same time. Exceptions will be made on a case-

by-case basis.

13. No vacations will be granted during the week prior to the In-service training exam.

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14. Exceptions will be made on a case-by-case basis for unscheduled absences, e.g. deaths, births, or

other family emergencies.

15. Vacations are not approved until all signatures (faculty service chief and program director) are

obtained on the vacation request form and it is returned to the program director’s office.

16. DO NOT make flight arrangements, reservations etc. until you are officially granted your vacation.

17. Three days, not included as vacation time, are granted for travel to conferences for presentations.

Copies of meeting and registration forms must be attached to the Travel Authorization form and have

the approved signature of the chairman.

18. Each resident (PGY-3 and above) is granted a TOTAL of five interview days. Any days necessary

above these five, will be taken as vacation days. (These days are only granted for job and/or

Fellowship interviews.) If a resident leaves at noon, ½ day will be charged to that resident.

19. Meeting/travel requests must also be approved by the Department Chair.

20. Requests for changes in vacation dates must be submitted in writing to the program director and will

be approved or denied on a case-by case basis. Revised 6/2015

VACATION POLICY OFF-SERVICE ROTATORS

The Department of Surgery recognizes that a significant number of residents rotating on our services will be

requesting vacation during their time on our services. Our goal is to maintain a healthy learning environment

while maximizing the educational experience of your residents. To help eliminate confusion and conflicts

the Department of Surgery has put together the following guidelines for off-service residents requesting

vacation while on a general surgery /sub-specialty service.

1. Vacation requests must be submitted 4 months in advance. Those requests falling in the first 4 months

of the year (July-Oct) must be submitted by July 31.

2. Vacations are not approved until all three signatures (service chief resident, faculty service chief and

Surgery program director) are obtained on the vacation request form and it is returned to the program

director or coordinator’s office.

3. DO NOT make flight arrangements, reservations etc. until you are officially granted your vacation.

4. All attempts will be made to accommodate each resident’s first choice. The administrative chief

resident and the program directors, if needed, will mediate disputes.

5. NO vacations will be permitted in July, the last 2 weeks of June, the last two weeks of December or

the first week of January. (Rare exceptions may be granted at the program director’s discretion) 6.

NO vacations will be granted during the week prior to the General Surgery In-service training exam

(the last week in January).

7. NO vacations will be permitted on the Trauma/SICU Services surrounding holidays. These include:

Fourth of July, Christmas, and New Year. (Rare exceptions may be granted at the program director’s

and head of Trauma’s discretion.) Residents will be assigned days off during either Christmas or

New Years.

8. All vacations must be taken in one-week intervals. Exceptions will be made on a case-by-case basis

in consultation with the administrative chief resident and the program director.

9. Only one week of vacation will be allowed per month per resident.

10. Only one week of vacation will be allowed per rotation per resident.

11. Only two total weeks per individual resident will be permitted while on the surgical services.

12. A week constitutes 7 consecutive days.

13. Only one resident per rotation may be on vacation at a particular time.

14. Exceptions will be made on a case-by-case basis for unscheduled absences, e.g. deaths, births, or

other family emergencies.

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15. All requests must be made on the Surgery department’s vacation request form. This form can be

obtained from the program administrator (Christy Hayes 293-7480).

16. Meeting/travel requests must be submitted one month prior to the rotation. These will be considered

on an individual basis. Only the days of the meeting and one travel day will be granted. Additional

days will be considered vacation.

17. If a resident is away from the service to attend a meeting, they will not be permitted to take a separate

vacation that same month.

18. Requests for exceptions to the above guidelines must be submitted in writing to the program director

and will be approved or denied on a case-by case basis.

We appreciate your co-operation and hope that by following the above guidelines, we will be able to

accommodate all residents’ vacation requests. Please see that each of your residents rotating with us receives

a copy of these guidelines.

Revised 6/2015

SICK LEAVE

Accumulation of Leave – Additional Information regarding leave can be found at www.hr.wvu.edu

Accumulation of sick leave is unlimited. Full-time regular classified staff and 12 month regular faculty

accrue 1.50 days of sick leave per month during active employment. If you are sick and need to “call-in” to

take a sick day you must do 3 things:

1. Contact the program director.

2. Contact the chief resident of your service

3. Contact or leave a voice mail message for Residency Program Administrator, Christy Hayes 293-

7480.

Sick time may be taken for:

1. Scheduled Doctor/Dentist appointment for employee

2. Non-scheduled appointment for employee’s child (i.e. called by caretaker or daycare that child is sick

and needs medical attention).

3. Funeral leave (3 days) for immediate family. If additional leave is required (i.e. extensive travel), it

must be approved by the Program Director.

4. Maternity/Paternity Leave

If you have any questions on whether sick time can be used or not, please contact the Residency Program

Administrator. Excessive/unexplained absences may affect your competency evaluation or even your

promotion to the next level of training.

MATERNITY AND PATERNITY LEAVE (FAMILY MEDICAL LEAVE)

Sick Leave/Short Term Disability is to be used for Maternity/Paternity Leave. If you have exhausted all of your

sick time to cover your time off, you will be required to use any unused vacation time.

Additional information regarding all leaves can be found www.hr.wvu.edu

In addition to WVU policies, the Accreditation Council for Graduate Medical Education (ACGME) and The

American Board of Plastic Surgery (ABPS) have requirements that must be followed in order to obtain your

42

certificate and sit for your boards. The ABPS (American Board of Plastic Surgery) has the following

requirements in regard to medical or maternity leave:

1 A leave of absence during training will NOT be included toward completion of the minimum

fortyeight (48) week/year requirement. This includes military leave and Paternity/Maternity leave.

Plastic Surgery Program Director must contact the Board in writing detailing any leave of absence

plans for residents during training.

2 The Board considers a residency in plastic surgery to be a full-time endeavor and looks with disfavor

upon any other arrangement. The minimum acceptable residency year, for both prerequisite and

requisite training, must include at least 48 weeks of full-time training experience per year.

3 Should absence exceed four (4) weeks per annum for any reason, the circumstances and the proposed

correction (i.e. make-up time) of this irregular training arrangement must be approved by the program

director.

4 The forty-eight (48) weeks can be averaged over the training years in the program. Any additional

months required in the program must be approved by the RRC-OS. Documentation of this approval

must be provided to the Board by the program director.

5 No credit, but no penalty, is given for military, maternity/paternity or other leaves during training.

PRACTITIONERS’ HEALTH COMMITTEE

The Practitioners’ Health Committee serves as a resource in the management of impaired physicians.

Impairment includes any physical, psychiatric or emotional illness that may interfere with the physicians’

ability to function appropriately and provide safe patient care. In an effort to ensure consistency in our

approach to these difficult problems, the Practitioners’ Health Committee has formulated the following

guidelines.

NEW RESIDENTS/FACULTY

Substance Abuse

Any resident or faculty member who requests an appointment to practice at WVUH who has a reasonable

suspicion of substance abuse or has a history of substance abuse and/or treatment of substance abuse must be

initially referred to the Practitioners’ Health Committee. The Practitioners’ Health Committee will determine

whether the resident or faculty needs additional evaluation from a psychiatrist or other person specializing in

substance abuse.

After receiving an evaluation, and consulting with the Department Chairperson, the Practitioners’ Health

Committee will make a recommendation concerning:

1. Advisability of an appointment to WVUH Need for restriction of privileges

2. Need for monitoring

3. Need for consent agreement concerning rehabilitation, counseling or other conditions of

appointment

Decision to grant Hospital staff privileges or allow residents to treat patients at WVUH, and under what terms

are at the discretion of the WVUH Board of Directors through the Joint Conference Committee and based

upon the recommendation of the Departmental Chairperson, the Vice-President of Medical Staff Affairs and

the Practitioners’ Health Committee.

These recommendations will be communicated to the GME office and the Program Director/Chair (for

residents), the Vice-President of Medical Staff Affairs and the Practitioners’ Health Committee.

43

If it is agreed that the resident or faculty is to have an appointed position at WVUH, the resident/faculty

member must sign an agreement that upon granting privileges, he/she will submit to a blood and urine drug

screening before assuming any patient care responsibilities.

Where the circumstances dictate a need for monitoring, the resident/faculty must sign an agreement that he/she

will meet with a member of the Practitioners’ Health Committee and agree to random blood and urine drug

screens and other conditions that the Committee determines are appropriate in their sole discretion as

requested by the Practitioners’ Health Committee, the Vice-President of Medical Staff Affairs, and other

supervisors.

All conditions of privileges and all test results will be communicated in writing to the GME office, Program

Director/Chair (for residents) and the Vice-President of Medical Staff Affairs.

Practicing Residents/Faculty

It is the responsibility of all faculties, residents, or any other person, to immediately report any inappropriate

behavior or other evidence of substance abuse/health problems that could impact on professional/clinical

performance in the Hospital. In addition, a resident or faculty member can and is required to self-refer to the

Practitioners’ Health Committee in the event that he/she experiences any substance abuse/health problem

which could impact on professional/clinical performance in the Hospital.

All such reported information shall be kept confidential except as limited by law, ethical violation, or when

patient safety is threatened.

If a Program Director/Chair or Vice-President of Medical Staff Affairs receives a report suggesting impairment

of a physician (faculty or resident) or observes behavior suggesting impairment, then the following actions are

required:

The Program Director/Chair or Vice-President of Medical Staff Affairs will do the best of his/her ability to

ensure that the allegation of impairment is credible.

The Program Director/Chair or Vice-President of Medical Staff Affairs must notify the Dean, the Vice-

President of Medical Staff Affairs (the Chairperson), and the Practitioners’ Health Committee (within twenty-

four (24) hours or within the next business day) in writing of any reported incidents or observed behavior

suggesting impairment.

The Program Director/Chair or Supervisor must immediately send the physician to Employee Health or the

Emergency Department for blood and urine drug screening, as set forth in WVUH policy. Refusal to cooperate

with testing is grounds for dismissal from the medical staff for faculty and removal of residents from providing

any patient care within the hospital.

The Program Director/Chair or Supervisor must immediately remove the physician from patient care or patient

contact.

The Program Director/Chair or Supervisor must immediately make a mandatory referral to the Employee

Assistance Program (EAP), based on the possibility of impaired performance.

The Program Director/Chair or Supervisor must immediately send the physician to Employee Health or the

Emergency Department for blood and urine drug screening, as set forth in WVUH policy. Refusal to cooperate

with testing is grounds for dismissal from the medical staff for faculty and removal of residents from providing

any patient care within the hospital.

44

The Program Director/Chair or Supervisor must immediately remove the physician from patient care or patient

contact.

The EAP office will require that the physician sign a release, authorizing exchange of medical information

between EAP, the Chairperson, WVUH, and the Practitioners’ Health Committee. EAP will provide a report

of their evaluation and treatment recommendations in a timely manner to the Dean, Practitioners’ Health

Committee, Chairperson, and the Vice-President of Medical Staff Affairs of WVUH.

The Practitioners’ Health Committee will review the report from the EAP and provide a recommendation to

the Vice-President of Medical Staff Affairs who will be responsible for the final decision concerning return

to work and monitoring. The Practitioners’ Health Committee will participate in the monitoring of physicians

until the rehabilitation or any disciplinary process is complete. All instances of unsafe treatment will be

reported to the Medical Executive Committee.

Other impairments (physical, emotional or psychological)

Any resident or faculty who requests an appointment to practice at WVUH where there is a physical, emotional

or psychological impairment that may interfere with the physicians’ ability to function appropriately and provide

safe patient care must be initially referred to the Practitioners’ Health Committee. The Practitioners’ Health

Committee will determine whether the resident or faculty needs additional evaluation from a psychiatrist or

other person specializing in the specific condition.

The same process will apply as above, however, there may be different or additional monitoring

required besides random blood and urine drug screens.

DISCIPLINE POLICY – DEPARTMENT OF SURGERY

Administrative responsibilities including accurate and timely documentation are vital to the practice of

medicine. Not only in regards to patient care but also in the maintenance of the Surgery Residency Program.

Throughout the surgery residency there are numerous administrative tasks in addition to documentation that

must be completed. Failure to do so violates the essence of Professionalism, one of the six core competencies.

These tasks include:

1. Weekly recording of duty hours

2. Monthly updates of Operative Logs

3. Yearly CBL’s

4. Reporting for semi-annual evaluation with the program director

5. Completion of USMLE Step III

6. Employee Health requirements

7. Fulfilling research requirements

8. Completing dictations within the allotted time frame.

Consequences:

A series of administrative steps have been approved by the Program Education Committee to correct

noncompliance. Residents will be reminded 10 days before the end of the month in an email containing a list

of tasks to be completed by the end of the month. On the first of the month, if the required administrative

tasks are not completed, the resident will be notified by the Residency Administration that his/her meal card

has been turned off. The meal card will remain off the number of days it took to complete the deficiencies.

If the deficiencies persist by the 15TH of the month the resident will be placed on administrative leave (see

below) until the delinquencies are corrected.

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Administrative Leave:

When a resident is on administrative leave, residents will relinquish all operative assignments during the day

but will fulfill all other floor care, clinic assignments and all other non-OR responsibilities. The timed freed

up from the operative theater will be used to complete the delinquencies. These residents will take call (night

time and weekends) as assigned. In addition, if a resident has been placed on administrative leave for a third

time in a single year, each day on administrative leave will consume one day of vacation time allotted. If a

resident has no vacation remaining or exceeds the number of days remaining, days will be subtracted from

the following year’s allotment. Upon completion of the missing documentation, the resident will contact the

Residency Program Administrator. Upon verification by the Residency Program Administrator that all

documentation requirements have been completed, the resident may return to full clinical status. If vacation

days were required, this will be communicated to the Program Director and a note placed into the resident’s

file. Residents accruing three Administrative leaves in any one PGY year or five during their residency, will

proceed to the next step.

Academic Probation:

Academic probation is a residency specific disciplinary action, which is not reportable or appealable. It does

not become part of the permanent record. Academic probation will last for a period of three months during

which the resident must comply with all Surgery, WVU School of Medicine, ACGME, and RRC policies.

If the resident violates any policy, s/he may be placed on Probation (see below).

Academic probation also applies to those who have failed to complete documentation while on administrative

leave, those who have accrued more than three administrative leaves in a single year, more than five

cumulatively in five years or have used all vacation time remaining in residency. With respect to

documentation, deficiencies must be completed and no further deficiencies develop. Should these two

conditions be met, the resident will return to normal status. Should deficiencies persist or new ones develop,

the resident will be placed on probation.

Probation:

Probation shall be instituted for three months. “Have you ever been on Probation?” is a question asked by

many states during the licensing process, hospital credentialing and insurance companies and thus should be

avoided to save time and angst in the future. During probation, the remedial plan consists of correction of

delinquencies and 100% compliance with all documentation and administrative requirements. If the resident

does not comply, see Final Actions.

Final Actions:

The Program Director may proceed directly to termination from the program or consider allowing the

resident to finish the year but not to be promoted to the next year. In the case of graduating residents, the

PD may decide that the resident has failed to satisfactorily complete the residency requirements and

therefore would be unable to validate residency training, an essential requirement for being accepted for

the Qualifying examination of the American Board of Surgery.

Duty Hours:

Failure to log Duty Hours 2 weeks within a single month constitutes one violation. Two violations over 2

months will place the resident on Administrative leave.

Three occurrences of Administrative Leave over 12 months leads to Academic Probation. Any subsequent

violation of Duty Hour recording in that year results directly in Probation.

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Case Logs:

Failure to update case logs by the last day of each month, will result in immediate Administrative Leave.

Placement on Administrative Leave 3 times in one PGY year or five occurrences during the program, will

result in Academic Probation.

USMLE/WV State Medical Licensure

Failure to complete the USMLE Step III exam by Dec 31 of the residents PGY II year results in immediate

Academic Probation.

Failure to apply for a WV State Medical License by April 1 of the PGY II year results in immediate Academic

Probation.

CBL’S:

Failure to complete required CBL’s by the assigned deadline, will result in Administrative leave.

ACADEMIC DISCIPLINE AND DISMISSAL POLICY

The Department of Surgery’s Plastic Surgery Program will follow the WVU School of Medicine GME and

ACGME policy on academic discipline and dismissal. This policy is derived from the SOM/GME by-laws

which can be found at http://medicine.hsc.wvu.edu/gme.

The Department of Surgery may take corrective or disciplinary action including dismissal for cause, including

but not limited to the following circumstances:

1. Unsatisfactory academic or clinical performance

2. Failure to comply with the policies, rules, and regulations of the SOM/GME by-laws Resident

Program, University or other facilities where the resident is trained

3. Revocation or suspension of license

4. Violation of federal and/or state laws, regulations, or ordinances

5. Acts of moral turpitude

6. Insubordination

7. Conduct that is detrimental to patient care

8. Unprofessional conduct.

Corrective or disciplinary actions may include but not limited to:

1. Issue a warning or reprimand

2. Impose terms of remediation or a requirement for additional training, consultation or treatment

3. Institute, continue, or modify an existing summary suspension of a resident’s appointment

4. Terminate, limit or suspend a resident’s appointment or privileges

5. Non-renewal of a resident’s appointment

6. Dismiss a resident from the Resident Program; or

7. Any other action that the resident’s program deems is appropriate under the circumstances.

Level I Intervention

Oral and/or Written counseling or other Adverse Action:

Minor academic deficiencies that may be corrected at Level I include: unsatisfactory academic or

clinical performance or failure to comply with the policies, rules, and regulations of the SOM/GME by-

laws Resident Program or University or other facilities where the resident is trained.

Corrective action for minor academic deficiencies or disciplinary offenses, which do not warrant

probation with remediation as defined in the Level II intervention, shall be determined and administered

47

by each Department. Corrective action may include oral or written counseling or any other action deemed

appropriate by the Department under the circumstances. Corrective actions for such minor academic

deficiencies and/or offenses are not subject to appeal.

Level II Intervention:

Probation/Remediation Plan or other Adverse Action:

Serious academic or professional deficiencies may lead to placement of a resident on probation. An

academic or professionalism deficiency that is not successfully addressed while on probation, may lead

to non-reappointment or other disciplinary action. The Program Director shall notify the resident in

writing that they have been placed on probation and the length of probation. A corrective and/or

disciplinary plan will be developed that outlines the terms and duration of probation and the deficiencies

for which probation was implemented. Failure of the resident to comply with the terms of the plan may

result in termination or non-renewal of the resident’s appointment.

Level III intervention:

Dismissal and/or Non-reappointment:

Any of the following may be cause for dismissal or non-reappointment including failure to comply or address

the deficiencies within the corrective and disciplinary plan as outlined in the Level II intervention:

1. Demonstrated incompetence or dishonesty in the performance of professional duties, including but not

limited to research misconduct.

2. Conduct which directly and substantially impairs the individual’s fulfillment of institutional

responsibilities, including but not limited to verified instances of sexual harassment, or of racial, gender-

related, or other discriminatory practices.

3. Insubordination by refusal to abide by legitimate reasonable directions of administrators or of the WVU

Board of Governors.

4. Physical or mental disability for which no reasonable accommodation can be made, and which makes

the resident unable, within a reasonable degree of medical certainty and by reasonably determined

medical opinion, to perform assigned duties.

5. Substantial and manifest neglect of duty.

6. Failure to return at the end of a leave of absence.

7. Failure to comply with all policies of WVU Hospitals, Inc.

A House Officer, who is dissatisfied with a Level II or Level III intervention, may appeal that decision by

following the Academic Grievance Policy and Procedure in Section XI of GME Bylaws.

ACADEMIC GRIEVANCE POLICY

Purpose. The purpose of this policy is to provide a mechanism for resolving disagreements, disputes and

complaints, which may arise between postgraduate residents and fellows and their Program Director or other

faculty member. The Department of Surgery abides by this Policy, which was derived from the WVU/GME

website by-laws at http://medicine.hsc.wvu.edu/gme.

Policy.

Postgraduate residents or fellows may appeal disagreements, disputes, or conflicts with the decisions and

recommendations of their program regarding academic related issues using the procedure outlined in this

section. This grievance procedure does not cover issues arising out of (1) termination of a resident/fellow

during an annual contract period; (2) alleged discrimination; (3) sexual harassment; (4) salary or benefit

48

issues. These grievances are covered under the employment grievance procedures for employees of West

Virginia University as outlined in section XXV of these bylaws.

Definitions

Grievance: any unresolved disagreement, dispute or complaint a resident or fellow has with the academic

policies or procedures of the Residency Training Program or any unresolved dispute or complaint with his

or her Program Director or other faculty member. These include but are not limited to issues of suspension,

probation, retention at current level of training, and refusal to issue a certificate of completion of training.

Procedure

Level I Resolution

A good faith effort will be made by an aggrieved resident/fellow and the Program Director to resolve

a grievance, which will begin with the aggrieved resident/fellow notifying the Program Director, in

writing, of the grievance within 10 working days of the date of receipt of the dispute or complaint.

This notification should include all pertinent information and evidence that supports the grievance.

Within ten (10) working days after notice of the grievance is received by the Program Director, the

resident/fellow and the Program Director will set a mutually convenient time to discuss the complaint

and attempt to reach a solution. Step I of the grievance procedure will be deemed complete when the

Program Director informs the aggrieved resident/fellow in writing of the final decision. This should

occur within 5 working days after the meeting between the resident/fellow and Program Director. A

copy of the Program Director’s final decision will be sent to the Department Chair and to the

Designated Institutional Official for GME (DIO). The resident/fellow is not entitled to legal

representation during the Level 1 meeting.

Level 2 Resolution

If the Program Director’s final written decision is not acceptable to the aggrieved resident/fellow, the

resident/fellow may choose to proceed to a Level 2 resolution, which will begin with the aggrieved

resident/fellow notifying the Department Chairman of the grievance in writing. Such notification must

occur within 10 working days of receipt of the Program Director’s final decision. If the Department

Chairman is also functioning as the Program Director, then the Level 2 resolution will be handled by

the DIO. If the aggrieved resident is a Transitional Year resident, then the DIO will appoint a

Department Chairman to handle the Level 2 grievance. This resident’s notification should include all

pertinent information, including a copy of the Program Director’s final written decision, and evidence

that supports the grievance. Within ten (10) working days of receipt of the grievance, the

resident/fellow and the Department Chairman or DIO will set a mutually convenient time to discuss

the complaint and attempt to reach a solution. Level II of this grievance procedure will be deemed

complete when the Department Chairman (or DIO) informs the aggrieved resident/fellow in writing of

the final decision. This should occur within 5 working days of the meeting with the resident/fellow and

the Chairman. Copies of this decision will be kept on file with the Program Director, in the Chairman’s

office and sent to the DIO. The resident/fellow is not entitled to legal representation during the Level 2

meeting.

Level 3 Resolution

If the resident/fellow disagrees with the Department Chairman’s final decision, he or she may pursue

a Level 3 resolution of the grievance. The aggrieved resident/fellow must initiate this process by

presenting their grievance, in writing, along with copies of the final written decisions from the

Program Director and Department Chairman, and any other pertinent information, to the office of the

49

Graduate Medical Education within 5 working days of receipt of the Department Chairman’s final

written decision. Failure to submit the grievance in the 5 working day time frame will result in the

resident/fellow waiving his or her right to proceed further with this procedure. In this situation, the

decision at Level II will be final. Upon timely receipt of the written grievance, the DIO will appoint

a Grievance Committee and will contact the aggrieved resident/fellow to set a mutually convenient

time to meet with them. The Grievance Committee will review and carefully consider all material

presented by the resident/fellow and his or her Program Director or the grievable party at the scheduled

meeting, following the protocol outlined in Section E. The Grievance Committee will provide the

aggrieved resident/fellow with a written decision within five working days of the meeting and a copy

will be placed on file in the Office of Graduate Medical Education, and with the Program Director

and Department Chair. The resident/fellow is not entitled to legal representation during the Level 3

meeting.

The Grievance Committee

Upon request for a formal resolution at Level III, the DIO will form a Grievance Committee composed

of at least two residents, and three Program Directors. No members of this committee will be from the

aggrieved resident’s/fellow’s own department. The DIO will choose a faculty member appointed to

the Grievance Committee to be the chair of the committee. The Grievance Committee hearing should

occur within 20 working days from receipt of the Level III grievance.

Grievance Committee Procedure

Attendance: All committee members should be present throughout the hearing.

The aggrieved resident/fellow must personally appear at the Grievance Committee meeting.

Conduct of Hearing: The chair will preside over the hearing, determine procedure, assure there is

reasonable opportunity to present relevant oral or written information, and maintain decorum. The

Chair will determine if information is relevant to the hearing and should be presented or excluded. The

aggrieved Resident may present any relevant information or testimony from any colleague or faculty

member. The Resident is NOT entitled to legal representation during the grievance committee hearing.

The Program Director and Department Chair may be requested by the Committee to also be present for

oral testimony. The committee chair is authorized to exclude or remove any person who is determined

to be disruptive.

Recesses and Adjournment: The committee chair may recess and reconvene the hearing by invoking the

right for executive session. Upon conclusion of the presentation of oral and written information, the

hearing record is closed. The Grievance Committee will deliberate in executive session outside the

presence of the involved parties.

Decisions: Decisions are to be determined by vote of a majority of members of the Committee and are

final. After deliberation, the Chair will prepare a written decision to be reviewed and signed by all of the

Committee members. The aggrieved resident/ fellow should be notified within 5 working days of the

hearing.

Meeting Record: A secretary/transcriptionist may be present for the purpose of recording the meeting

minutes. Minutes and the final written decision of the Committee will be placed on file in the Office

GME, and by the Department in the resident or fellow’s academic file.

50

Confidentiality

All participants in the grievance are expected to maintain confidentiality of the grievance process by

not discussing the matter under review with any third party except as may be required for purposes of

the grievance procedures.

Conditions for Reappointment:

1. Promotion: Decisions regarding resident promotion are based on criteria listed above, and

whether resident has met all departmental requirements. The USMLE is to be used as a measure

of proficiency. Passage of the USMLE, step 3 is a requirement for advancement for the 3rd year

of residency as indicated in Section VII. Resident Doctor Licensure Requirement.

2. Intent Not to Renew Contract: In the event that WVU School of Medicine elects not to reappoint

a resident to the program and the agreement is not renewed, WVU shall provide the resident with

a four (4) month advance written notice of its determination of non-reappointment unless the

termination is “for cause.”

PROGRAM CLOSURE/REDUCTION POLICY

In the event that the Plastic Surgery Residency program is closed, reduced or discontinued, the department

will inform the residents in writing as soon as possible. If a resident is unable to complete his/her training in

the program, the department will make a good faith effort to assist the resident in enrolling in an ACGME

accredited program in the same specialty at the appropriate PGY level.

51

CONFLICT OF INTEREST DISCLAIMER I am aware that this educational resource been provided to the West Virginia University Department of Surgery,

by support from an outside source/industry. I also understand that I have no obligation to use, buy or promote

any products from this company. I have no personal, financial or professional responsibility to this company

by accepting this gift.

GIFT:

INDUSTRY/COMPANY:

DATE:

NAME(print):

NAME(signature):

EDUCATIONAL RATIONAL:

PROGRAM DIRECTOR:

DATE: __________________

52

RESIDENT CONTRACT REVIEW

NOTIFICATION OF TERMS AND

CONDITIONS OF APPOINTMENT

MEDICAL AND DENTAL RESIDENTS

Name: «Name» Annual Salary: «PGSALARY».00

Administrative Supplement: «SUPPLEMENT».00

CollegeCollege of Medicine

TitleMedical Resident

«start_date»

Start

Stop«end_date»

Appointment: This appointment is made by virtue of the authority vested by law in the West

Virginia University Board of Governors and is subject to and in accordance with the

provisions of the rules, regulations and policies of the governing board.

1. Conditions of Employment:

Consistent with the provisions of the rules, regulations, and policies of the governing

board and of West Virginia University, this appointment and/or compensation is/are

subject to the fulfillment of the responsibilities of the position during the term of the

appointment, the availability of the state funding, and the following:

2. License to Practice Medicine/Dentistry:

If the medical resident holds a Medical Doctor (M.D.) degree and has already completed

twelve months of residency training and is otherwise eligible for licensing, this

appointment is subject to resident obtaining and maintaining an unrestricted license to

practice medicine from the State of West Virginia and/or from any other State's licensing

authority where resident has been assigned by the Dean of the School of Medicine. If the

medical resident holds a Doctor of Osteopathy (D.O.) degree, this appointment is subject

to resident obtaining and maintaining an unrestricted license to practice medicine

from the State of West Virginia Board of Osteopathy and/or from any other State's

licensing authority where resident has been assigned by the Dean of the School of

Medicine. In the case of dental residents, this appointment is subject to resident obtaining

and maintaining an unrestricted license to practice dentistry from the State of West

Virginia and/or from any other State's licensing authority where resident has been

assigned by the Dean of the School of Dentistry.

53

3. Resident Responsibilities:

This appointment is subject to resident obtaining and maintaining a resident appointment

at the affiliated hospital(s) to which resident is assigned by the Dean of the West Virginia

University School of Medicine or Dentistry. The resident shall be subject to all policies,

rules, and regulations of said affiliated hospitals(s).

4. Health Maintenance Organizations, Managed Care Entities and Other Purchasers of

Health Care: Resident's signature below in acceptance of this appointment shall constitute

the authorization by resident for the School of Medicine or Dentistry or affiliated hospitals

of the School of Medicine or Dentistry, to release confidential information concerning

resident's education, skills, quality of care, utilization, and patient care experience to health,

maintenance organizations, managed care entities and other purchasers of health care that

contract for the provision of professional medical/dental services by residents. The resident

participating in managed care activities shall be subject to all policies, rules, regulations and

agreements of said organizations or entities.

5. Benefits:

Information on benefits including conditions for reappointment, conditions under which

living quarters, meals, laundry are provided, professional liability insurance, liability

insurance coverage for claims filed after completion of program, and health and

disability insurance can be found in the Resident Manual and the GME/WVU Bylaws,

in print and on the GME website, at www.hsc.wvu.edu/som/gme.

54

MISCELLANEOUS/FORMS

P.O. Box 9238, HSCN, Morgantown, WV 26506-9238

VACATION AND MEETING REQUEST FORM

RESIDENT:

(Circle One): VACATION / MEETING

DATES OF TRAVEL:

(Only if attending meeting) LOCATION:

(Please Print) TITLE OF ABSTRACT/PAPER OR POSTER (Please have completed and

attached Authorization to Travel Form): __________________

(If presenting abstract/paper or poster) SPONSORING FACULTY MEMBER(S):

CHIEF FACULTY MEMBER SIGNATURE OF SERVICE FROM WHICH YOU WILL

BE ABSENT:

CHIEF RESIDENT OF SERVICE SIGNATURE: AD-

MINISTRATIVE CHIEF SIGNATURE:

PROGRAM DIRECTOR’S SIGNATURE:

Please return completed form to: Christy Hayes, Program Manager

West Virginia University

P.O. Box 9238

Morgantown, WV 26506-9238

55

REQUEST FOR AUTHORIZATION TO TRAVEL